Every finding on record at Advanced Health Care of Aurora

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on two out of three units.Specifically, the facility failed to:-Ensure resident rooms were cleaned in a sanitary manner; -Implement a water management plan; and,-Ensure vital sign machines were disinfected between residents.Findings include:I. The facility failed to ensure proper disinfectant practices were followed during housekeeping.A. Professional referenceThe Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, revised 3/19/24w, as retrieved on 6/29/26 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms.B. Facility policy and procedureThe Housekeeping Services policy, undated, was received from the nursing home administrator (NHA) on 6/25/26 at 5:29 p.m. It read in pertinent part, To effectively monitor infections within the facility by gathering data and assessing possible trends; to assist in minimizing the spread of infection within the facility. Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior environment are provided. Sufficient housekeeping personnel and equipment is provided to maintain the interior and exterior of the facility in a safe, clean, orderly and attractive manner. C. ObservationsOn 6/24/26 at 9:57 a.m. housekeeper (HK) #1 was cleaning room [ROOM NUMBER], a single occupancy room. At 10:05 a.m. HK #1 wiped the inside of the sink that was in the bedroom, then wiped the faucet and handles, and then the counter top. At 10:10 a.m. HK #1 wiped the inside of the bathroom sink bowl, then wiped the faucet and handles and then the counter top. -HK #1 failed to clean from the cleanest to dirtiest areas of the sink.On 6/24/26 at 11:09 a.m. HK #2 was cleaning an unidentified single occupancy room.At 11:13 a.m. HK #2 wiped the inside of the bathroom sink with a rag, then wiped the counter top and the bathroom railing/grab bar with the same rag.-HK #2 failed to clean from the cleanest to dirtiest areas of the sink.D. Staff interviewsHK #1 was interviewed on 6/24/25 at 10:21 a.m. H K#1 said the inside of the sink may be dirty because residents brushed their teeth in the sink bowl or residents may wash their hands in there, which could contain stool or urine. HK #1 said once she wiped the inside of the sink bowl she should use a different rag. HK #2 was interviewed on 6/24/26 at 2:00 p.m. HK #2 said the inside of the sink had more bacteria than the outside of the sink. HK #2 said she may have cleaned the sink in the incorrect manner. HK #2 said she was supposed to change her rag after cleaning the inside of the sink so that she did not contaminate the outside of the sink with her dirty rag. The housekeeping director was interviewed on 6/25/26 at 11:36 a.m. The housekeeping director said when cleaning a sink, housekeepers should clean from clean to dirty. The housekeeping director said it would not be appropriate for housekeepers to wipe the inside of the sink and then use the same rag to wipe the sink handles, counter top, or bars after already wiping the inside of the sink. The housekeeping director said the facility would provide education to the housekeepers to ensure they were cleaning properly, as he wanted to ensure germs were not getting spread around.II. The facility failed to implement a water management [NAME]. Professional referenceThe Centers for Disease Control and Prevention (CDC) Overview of Water Management Programs, revised 3/15/24, was retrieved on 6/29/26 from https://www.cdc.gov/control-legionella/php/wmp/index.html. It read in pertinent part, Developing and maintaining a water management program is a multi-step process that requires continuous review. The seven steps of a Legionella water management program are to:-Establish a water management program team;-Describe the building water systems;-Identify areas where Legionella could grow and spread;-Decide where to apply and how to monitor control measures;-Establish interventions when control limits are not met;-Ensure the program runs as designed and is effective; and,-Document and communicate all the activitiesThe Centers for Disease Control and Prevention (CDC) Monitoring Building Water, revised 3/15/24, was retrieved on 6/29/26 from https://www.cdc.gov/control-legionella/php/guidance/monitor-water-guidance.html. It read in pertinent part, It's important to monitor the temperature, disinfectant residuals, and pH of building water, and identify areas where water moves slowly. Promptly addressing any identified issues can help reduce the risk of Legionella growth and spread within a building's water system. Legionella grows best between 77 degrees Fahrenheit (F) to 113 degrees F (25 degrees Celsius to 45 degrees Celsius). There's potential for Legionella growth in the absence of other Legionella controls under either of the following conditions: Cold water temperatures rise above 77 degrees F (25 degrees Celsius). Warm water temperatures fall below 120 degrees F (49 degrees Celsius). Measure disinfectant residual. Maintaining a disinfectant residual throughout a system can help prevent Legionella growth. Action: Measure the disinfectant residual to confirm its presence. Measure pH. Certain disinfectants work best within an optimal pH range. Identify areas where water moves slowly. Slowly moving or stagnant water increases water age, which provides opportunities for Legionella growth. Increased water age also contributes to disinfectant residual loss and water temperatures favorable for Legionella. Action: Look for faucets or fixtures that aren't used regularly and flush them to maintain water flow.B. Facility policy and procedureThe Legionnaire's Disease Legionella policy and procedure, undated, was received from the NHA on 6/25/26 at 5:29 p.m. It read in pertinent part, Legionnaires' disease is not transmitted person to person; therefore, residents with Legionnaires' disease can be cared for using standard precautions.-However, the Legionnaire's Disease / Legionella policy and procedure did not provide guidance on Legionnaire's preventative measures specifically related to a water management program.C. Record review The facility's water management plan was requested on 6/24/26 at 2:00 p.m. The maintenance director said the facility did not have a current water management plan (see interviews below).D. Staff interviewsThe maintenance director was interviewed on 6/24/26 at 2:00 p.m. The maintenance director said the facility had undergone a change in maintenance directors. The maintenance director said the previous maintenance director had a binder which contained a water management plan and supplies/ordering information. The maintenance director said the information was not passed on before the previous manager left the facility. The maintenance director said the facility did not currently have a physical log or binder which contained legionella tracking and testing information. The maintenance director said the facility was currently out of legionella testing supplies. The maintenance director said the facility had not tested the building's water for legionella for a couple of months because the facility needed supplies. The maintenance director said the facility planned to order additional supplies immediately.III. The facility failed to ensure vital sign machines were disinfected between residentsA. Professional referenceThe Centers for Disease Control and Prevention (CDC) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, revised 4/12/24 was retrieved on 6/29/26 from https://www.cdc.gov/infection-control/hcp/core-practices/index.html. It read in pertinent part, Clean and reprocess (disinfect or sterilize) reusable medical equipment (blood glucose meters and other point-of-care devices, blood pressure cuffs, oximeter probes, surgical instruments, endoscopes) prior to use on another patient or when soiled.B. Facility policy and procedureThe Infection Control Surveillance and Reporting policy and procedure, undated, was received from the nursing home administrator (NHA) on 6/25/26 at 5:29 p.m. It read in pertinent part, Routine Surveillance will be conducted via walking rounds, observation and evaluation of patient care techniques, and review of patient records. Routine Surveillance will be conducted via walking rounds, observation and evaluation of patient care techniques, and review of patient records. The IP will evaluate all Healthcare Associated and Community Acquired infections for appropriate interventions such as isolation precautions and other patient care practices to reduce the spread of infectious organisms and maintain a safe and healthy environment for patients, employees and visitors.C. ObservationsOn 6/22/26 at 2:06 p.m. an unidentified certified nursing aide (CNA) left a resident's room with a vitals machine and entered room [ROOM NUMBER]. At 2:06 p.m. the same CNA left room [ROOM NUMBER] with the vitals machine, left to retrieve a pulse oximeter from the nurses station, and entered room [ROOM NUMBER]. The CNA did not have wipes or spray present on the vitals cart. No hand hygiene was performed between rooms. On 6/23/26 at 3:18 p.m. in hallway number three, an unidentified CNA went from one resident's room to another resident's room with the vital signs cart machine. The unidentified CNA did not clean the vital signs machine between taking the resident's vital signs. On 6/24/26 at 2:36 p.m. an unidentified CNA was taking resident's vital signs. The unidentified CNA used the blood pressure cuff on a resident in room [ROOM NUMBER] and then took the vitals cart into room [ROOM NUMBER] and took the resident's vital signs. The unidentified CNA did not clean the blood pressure cuff or vital signs machine in between resident uses.D. Staff interviewsThe infection preventionist was interviewed on 6/25/26 at 12:43 p.m. The infection preventionist said the CNAs should be cleaning vital sign equipment between residents for sanitary purposes.The director of nursing (DON) was interviewed on 6/25/26 at 12:43 p.m. The DON said CNAs should be cleaning vital signs equipment when using after each resident as a best practice.

Based on observations and interviews, the facility failed to ensure residents were provided services that meet professional standards for three (#42, #63 and #50) of six residents out of 39 sample residents.Specifically, the facility failed to:-Hold Resident #42's antihypertensive medication per physician's order;-Hold laxative medications for Resident #50 and Resident #63 per physician's orders; and,-Administer Resident #50's Eliquis (an anticoagulant medication) and duloxetine (an antidepressant medication) per physician's order. Findings include: I. Facility policy and procedure The Administration of Medications policy and procedure, undated, was received from the nursing home administrator (NHA) on 6/25/26 at 5:29 p.m. It read in pertinent part, Verify the six medication administration rights: 1. Right patient 2. Right drug 3. Right dose 4. Right dosage form 5. Right route 6. Right time Ensure ancillary tasks such as blood pressure or apical pulse are performed with appropriate medications. If a medication is unavailable, contact the pharmacy and request the medication stat (immediately). If unable to obtain the medication during the administration time, contact the provider for further orders. II. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, acute kidney failure, chronic obstructive pulmonary disease, congestive heart failure and atrial fibrillation. According to the 5/18/26 minimum data (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record review The cardiac care plan, revised 4/28/26, revealed Resident #42 had a diagnosis of hypertension. Pertinent interventions included administering medications per Resident #42's physician's orders and notifying the physician as needed. Review of Resident #42's May 2026 and June 2026 CPO, from 5/1/26 through 6/25/26, revealed the following physician's orders: -Hold hypertension medications for systolic blood pressure (SBP) less than 100 milligrams of mercury (mmHg) or diastolic blood pressure (DBP) less than 50 mmHg, ordered 5/5/26; -Nebivolol 5 milligram (mg) tablets, give 5 mg by mouth once a day for hypertension, ordered 5/5/26 and discontinued 5/28/26; -Nebivolol 5 mg tablets, give 2.5 mg by mouth once a day for hypertension, ordered 5/28/26 and discontinued 6/8/26; and, -Nebivolol 5 mg tablets, give 2.5 mg by mouth once a day for hypertension and atrial fibrillation, ordered 6/8/26. Review of Resident #42's May 2026 medication administration record (MAR), from 5/5/26 through 5/31/26, revealed the following: -Resident #42's SBP was measured and documented to be less than 100 mmHg on 5/24/26 and 5/31/26, and her nebivolol was documented as administered. Review of Resident #42's June 2026 MAR, from 6/1/26 through 6/23/26, revealed the following: -Resident #42's SBP was measured and documented to be less than 100 mmHg on 6/7/26, 6/13/26 and 6/14/26, and her nebivolol was documented as administered. -Review of Resident #42's electronic medical record (EMR) did not reveal any documentation indicating the resident's physician was notified regarding the resident's blood pressure being low during any of the above administrations. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 6/24/26 at 3:48 p.m. LPN #2 said before administering an antihypertensive medication, she checked the resident's vital signs and assessed their condition to ensure they were feeling stable and not dizzy. LPN #2 said she would check the CPO to see what parameters the physician had ordered to see if she needed to hold the medication. LPN #2 said there were usually orders to hold antihypertensive medications if the resident's SBP was below 100 mmHg or if their DBP was below 40 mmHg. LPN #2 said she would alert the resident's physician if their blood pressure was low to see if she could administer the medication later if the resident's blood pressure returned to a normal threshold. LPN #2 said if a resident's blood pressure was low and there was no hold order she would still hold the medication and alert the resident's physician. LPN #2 said she would need to hold the antihypertensive medication if a resident's blood pressure was low because the medication would make the resident's blood pressure even lower. Registered nurse (RN) #2 was interviewed on 6/25/26 at 2:27 p.m. RN #2 said for residents on antihypertensive medications, the certified nurse aides (CNA) checked their vital sign measurements, including blood pressure, prior to administration. RN #2 said if a resident's blood pressure was low they would encourage fluids and monitor the resident. RN #2 said Resident #42 was on nebivolol, a medication used to treat high blood pressure. RN #2 said she held Resident #42's nebivolol that morning (6/25/26) because her blood pressure was too low. RN #2 said she had to contact the resident's physician if she withheld a medication, and said there were orders to hold the nebivolol if Resident #42's blood pressure dropped below a certain threshold. RN #2 said she would hold the nebivolol if Resident #42's blood pressure was low because the medication would drop her blood pressure even lower. The director of nursing (DON) and the nurse manager were interviewed together on 6/25/26 at 3:25 p.m. The DON said nursing staff should follow the physician's orders for antihypertensive medications when administering them. The nurse manager said the facility used standing hold orders for most residents in which the medication would be held if their SBP was lower than 100 mmHg or their DBP was lower than 50 mmHg. The nurse manager reviewed Resident #42's June 2026 CPO and said there were no specific hold orders for her nebivolol order. The DON said the nursing staff would then defer to the standing hold parameters of 100/50 mmHg. The nurse manager and DON said the nursing staff should have consulted with Resident #42's physician if they were unsure if they should hold the nebivolol.The DON said the nursing staff may have verbally consulted with Resident #42's physician or medical providers but said the nursing staff should have documented that discussion in Resident #42's EMR. The DON said antihypertensives should be held when a resident's blood pressure was low to prevent their blood pressure from dropping lower. The nurse practitioner (NP) was interviewed on 6/25/26 at 4:27 p.m. The NP said antihypertensive medications should be administered per physician's orders, and said the facility used standing orders for the nursing staff to know when to hold the medications. The NP said if a resident's blood pressure was low, the nursing staff should communicate with one of the resident's medical providers, as sometimes if a medication was also being used to treat arrhythmias the provider may approve administering the medication despite a low blood pressure. The NP said he did not think the nursing staff would need to document that communication. The NP said nursing staff should reach out to the resident's physician if they were unclear with any of the resident's medication orders. III. Resident #63 A. Resident status Resident #63, age [AGE], was admitted on [DATE] and discharged to another facility on 6/25/26. According to the June 2026 CPO, diagnoses included displaced fracture of left femur, hypertensive chronic kidney disease, type 2 diabetes and vascular dementia with anxiety. According to the 6/22/26 BIMS assessment, the resident had severe cognitive impairments with a BIMS score of six out of 15. B. Resident representative interview Resident #63's representative was interviewed on 6/25/26 at 10:11 a.m. The resident's representative said Resident #63 had been having diarrhea since Saturday (6/20/26) and had been receiving a laxative medication since then as well. The resident's representative said she entered the facility on Monday (6/22/26) and found Resident #63 sitting in bed in an incontinence brief which was soiled with diarrhea, and said the resident appeared dehydrated at the time. The resident's representative said she brought this issue to the attention of the NHA and said the nursing staff had increased her hydration over the last few days, but said she was concerned about the resident receiving a laxative while having diarrhea. C. Record review The incontinence care plan, initiated during a prior stay on 11/17/25, revealed Resident #50 had episodes of urinary and bowel incontinence. Pertinent interventions included notifying the physician if signs or symptoms occurred and providing peri-care after each incontinence episode. Review of Resident #63's June 2026 CPO revealed the following order: -Senna laxative 8.6 mg tablets, give two tablets by mouth once a day for constipation prevention, hold for loose stools, ordered 6/18/26. Review of Resident #63's bowel movement records from 6/18/26 through 6/25/26 revealed the following: -Resident #63 was documented to have had a loose or liquid bowel movement on 6/20/26, 6/21/26, 6/22/26 and 6/23/26. -Resident #63 additionally had bowel movements documented on 6/21/26 and 6/23/26 with no description of their consistency noted. Review of Resident #63's June 2026 MAR, from 6/18/26 through 6/25/26, revealed the Senna laxative order was marked as administered each day from 6/19/26 through 6/25/26. -Resident #63 received Senna from 6/20/26 through 6/23/26 despite having noted loose or liquid stools during that time. A progress note, dated 6/23/26 at 9:11 a.m., revealed Resident #63 was seen by her physician's assistant (PA). The progress note documented the PA discussed Resident #63's plan and progress with the nursing staff and therapy team. Resident #63 endorsed some mild constipation and did not have any complaints of diarrhea. The PA documented Resident #63's constipation was discussed with the internal medicine team and Senna was continued. -However, Resident #63 was experiencing loose and liquid bowel movements at the time. -Review of Resident #63's EMR did not reveal any documentation indicating the resident's physician was contacted regarding or informed of her loose stools. IV. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included chronic pancreatitis, generalized muscle weakness, polyneuropathy and anemia. According to the 6/11/26 BIMS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. B. Resident interview Resident #50 was interviewed on 6/22/26 at 10:39 a.m. Resident #50 said she had been having terrible diarrhea for the last four days. Resident #50 said she had not been given anything by the nursing staff that seemed to improve her diarrhea. Resident #50 was interviewed a second time on 6/24/26 at 1:37 p.m. Resident #50 said the facility had started working to address her diarrhea. Resident #50 said her stools had otherwise been normal in color, just loose. C. Record review A bowel care plan, revised 6/16/26, revealed Resident #50 had episodes of bowel incontinence. Pertinent interventions included notifying the physician if signs or symptoms occurred and providing peri-care after each incontinence episode. Review of Resident #50's June 2026 CPO revealed the following orders: -Senna laxative 8.6 mg tablets, give two tablets by mouth once a day for constipation prevention, hold for loose stools, ordered 6/8/26; -Lactobacillus acidophilus oral capsule, give one capsule once a day for gastrointestinal support, ordered 6/8/26; -Cholestyramine powder, give one packet once a day as needed for loose stools, ordered 6/10/26; -Cholestyramine powder 4 mg, give 4 mg by mouth once a day for stool bulking, ordered 6/23/26 (during the survey); -Loperamide (Imodium) 2 mg oral tablet, give one tablet once a day for loose stools, ordered 6/24/26 (during the survey); and, -Imodium 2 mg oral tablet, give one tablet three times a day as needed for loose stools, ordered 6/25/26 (during the survey). Review of Resident #50's bowel movement records from 6/8/26 through 6/25/26 revealed the following: -Resident #50 was documented to have had a loose bowel movement on 6/17/26, 6/20/26, and 6/25/26 -On 6/19/26 Resident #50 had a liquid bowel movement; -Resident #50 additionally had documented bowel movements on 6/8/26, 6/13/26, 6/18/26, 6/19/26, 6/23/26 and 6/24/26 with no description of their consistency noted. Review of Resident #50's June 2026 MAR, from 6/8/26 through 6/25/26, revealed the following: -The Senna laxative order was held on 6/12/26 and 6/25/26 due Resident #50's complaints of diarrhea. -Resident #50 refused the Senna laxative on 6/17/26 through 6/19/26, 6/23/26 and 6/24/26. -Resident #50 received Senna on 6/20/26 despite having a documented loose bowel movement that morning, and was offered the medication on multiple dates despite having loose stools at the time. A progress note, dated 6/24/26 at 2:24 p.m., revealed Resident #50 was seen by her physician. Resident #50 was on an antidiarrheal medication but complained of persistent diarrhea. Resident #50 wanted to know if she could take Imodium as well as it had worked better for her in the past. Resident #50 reported her diarrhea started on 6/20/26 or before. D. Staff interviews RN #2 was interviewed on 6/25/26 at 2:27 p.m. RN #2 said Resident #50 had been having loose stools and said she was taking Imodium. RN #2 said she had to talk to Resident #50's provider to get additional doses of Imodium ordered as she had only had an order for Imodium at night. RN #2 said she would hold laxative medications when a resident was having loose stools, as administering a laxative would just cause them to have more loose stools. RN #2 said Resident #50 went between being constipated to having loose stools. CNA #2 was interviewed on 6/25/26 at 2:52 p.m. CNA #2 said if a resident had two or three loose bowel movements she would report it to the nurse. CNA #2 said her nurse told her Resident #50 had loose stools earlier that morning, and said she had not heard any report of Resident #63 having loose stools. CNA #3 was interviewed on 6/25/26 at 2:56 p.m. CNA #3 said Resident #50 told her she was having loose stools the day prior (6/24/26), but said she was not working with her that day so she was not sure if her stools were actually loose or not. CNA #3 said if a resident was having multiple bouts of diarrhea, maybe four to five bouts, she would tell the nurse about it. CNA #3 said she would otherwise just check on the resident more frequently. The DON and the nurse manager were interviewed together on 6/25/26 at 3:25 p.m. The DON said CNAs would report loose stools to the nurse, and the nurse would follow up to see if the resident had chronic loose stools. The DON said laxative medications would need to be held for any loose stools, and said this was usually noted in the physician's order. The DON said Resident #50 had chronic pancreatitis and constipation. The nurse manager reviewed Resident #50's record and said she had not received Senna on 6/17/26 through 6/19/26 and 6/23/26 through 6/24/26 due to the resident refusing the medication. The DON said Resident #50's Senna order read to hold the order for loose stools and said the nursing staff should not have offered it to Resident #50 while she was having loose stools. The DON said Resident #63's representative complained she was having diarrhea and said Resident #63 was getting Senna at night. The nurse manager said Resident #63 had documented loose bowel movements on 6/20/26, 6/21/26 and 6/23/26. The nurse manager said Resident #63's Senna order said to hold the medication for loose stools. The DON said Resident #63 would have needed her Senna held due to her loose stools. The DON said laxative medications needed to be held when residents were having diarrhea due to the risk of dehydration. The DON said she saw a note from Resident #63's physician from 6/22/26 in which the resident endorsed constipation and noted per the hospital to continue administering Senna. The DON said the note documented the physician discussed Resident #63's case and progress with the nursing staff. The NP was interviewed on 6/25/26 at 4:27 p.m. The NP said he was aware of Resident #63 having loose stools. The NP said the facility had been monitoring the resident for dehydration to ensure she was not getting dehydrated. The NP said Resident #63 was receiving Senna and said the laxative should have been held if she was having loose stools. The NP said if a resident experiencing loose stools received a laxative medication the nursing staff would need to monitor them for any dehydration or medication side effects. -However, review of Resident #63's EMR did not reveal any documentation indicating the NP had been notified of the resident's loose stools or any monitoring for signs or symptoms of dehydration. V. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the June 2026 CPO, diagnoses included atrial fibrillation, generalized muscle weakness, polyneuropathy, chronic pancreatitis and anemia. According to the 6/11/26 BIMS assessment, the resident was cognitively intact with a score of 15 out of 15. B. Record review Review of Resident #50's June 2026 CPO revealed the following physician orders: On 6/25/26 at 9:15 a.m. RN #2 was preparing and administering medications for Resident #50. Resident #50 had the following medications ordered: -Eliquis (apixaban) 2.5 mg tablet, give 2.5 mg twice a day for clot prophylaxis, ordered on 6/8/26. -Duloxetine 30 mg capsule, give 30 mg once a day for neuropathy, ordered 6/8/26. C. Observations and staff interview On 6/25/25 at 9:15 a.m. RN #2 was preparing medications for Resident #50. RN #2 was unable to find the duloxetine or Eliquis for Resident #50. -Resident #50 did not receive these medications during the medication pass. D. Additional staff interviews RN #2 was interviewed on 6/25/26 at 9:20 a.m. RN #2 said she would let the physician assistant (PA) know that the medications were not available during rounds which occurred around 9:00 a.m. to 10:00 a.m. RN #2 said she would request the medications from the pharmacy. RN #2 was interviewed on 6/25/26 at 3:34 p.m. RN #2 said the pharmacy had not delivered the medications yet. RN #2 said the last refill was on 6/8/26. RN #2 said the nurses requested medication refills electronically and also faxed the pharmacy to get medications refilled. The pharmacist was interviewed on 6/25/26 at 4:08 p.m. The pharmacist said Eliquis was an anticoagulant that prevented blood clots from forming. The pharmacist said Eliquis was often used for people who had atrial fibrillation. The pharmacist said that taking all doses was important. The pharmacist said there was a small risk of forming a clot if the dose was missed by a few hours. The pharmacist said duloxetine had a long half life so the drug stays in the system for a long time. The pharmacist said if duloxetine was late for a few hours, it should not affect the resident a lot. The pharmacist said the facility had to request new or additional medications from the pharmacy. The pharmacist said the facility normally requested a refill request via fax, phone call, or electronically. The pharmacist said once the pharmacy received the request, they delivered the medication within one business day, The pharmacist said they provided three deliveries per day to the facility. The pharmacist said the last time the medications were requested and delivered was on 6/8/26. The pharmacist said the medications were also requested that morning on 6/25/26 and the medications were in route to be delivered to the facility. The DON was interviewed on 6/25/26 at 5:09 p.m. The DON said that the three medications were not delivered by pharmacy yet. The DON said that eliquis was a blood thinner and it helped prevent blood clots from forming. The DON said duloxetine was used for pain or depression. The DON said that Resident #50's duloxetine was ordered for peripheral neuropathy. The DON said that nurses should reorder medications. The DON said the nurses should have requested the medications 72 hours prior to running out of supply, so that the facility did not run out of medication and so the resident did not go without medications. The DON said that Eliquis and duloxetine were not present in the emergency medication supply kit, but that the facility was working to increase the medications available in the kit. The DON said if nurses did not have medications present in the medication cart, they should check their resources and emergency supplies. The DON said that nurses should notify the provider that they did not have the medication available and also let the family know. The DON said nurses should let her know if they did not have medications available to give residents so she could reach out to the pharmacy.

Based on record review, interviews, and observations, the facility failed to prevent medication administration errors.Specifically, the facility had a medication error rate of 8.1%, which was three errors out of 37 opportunities for error.Findings include:I. Professional referenceAccording to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2021), E. [NAME], St. Louis Missouri, pp. 605-606. A medication error is any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication.II. Facility policy and procedureThe Medication Error policy, revised May 2026, was received from the nursing home administrator (NHA) on 6/25/26 at 5:29 p.m. It read in pertinent part, Medication errors are to be minimized by following the six rights of medication administration. The director of nursing will track and report the facility's medication error rate to the Quality Assurance Committee at least quarterly.B. Record reviewReview of Resident #50's June 2026 CPO revealed the following physician orders:On 6/25/26 at 9:15 a.m. registered nurse (RN) #2 was preparing and administering medications for Resident #50. Resident #50 had the following medications ordered:-Eliquis (Apixaban) (blood thinner) 2.5 milligram (mg) tablet, give 2.5 mg twice a day for clot prophylaxis, ordered on 6/8/26.-Duloxetine (antidepressant medication) 30 mg capsule, give 30 mg once a day for neuropathy, ordered 6/8/26.-Aspirin (an antiplatelet medication that works to inhibit platelet aggregation) 81 mg tablet, give 81 mg once a day for clot prophylaxis, ordered on 6/8/26.C. Observations / interview On 6/25/25 at 9:15 a.m. RN #2 was preparing medications for Resident #50. RN #2 was unable to find the duloxetine, eliquis, and aspirin for Resident #50. -Resident #50 did not receive these medications during the medication pass. Cross reference F760: failure to prevent a significant medication error.D. Staff interviewsRN #2 was interviewed on 6/25/26 at 9:20 a.m. RN #2 said she would let the physician assistant (PA) know that all three drugs were not available during rounds which occurred around 9:00 a.m to 10:00 a.m. RN #2 said she requested t the medications from the pharmacy. RN #2 was interviewed on 6/25/26 at 3:34 p.m. RN #2 said the pharmacy had not delivered the medications yet. RN #2 said the last refill was on 6/8/26. RN #2 said nurses requested medication refills electronically and also faxed the pharmacy to get medications refilled.The pharmacist was interviewed on 6/25/26 at 4:08 p.m. The pharmacist said eliquis was an anticoagulant that prevented blood clots. The pharmacist said that taking all doses was important. The pharmacist said that duloxetine was a SNRI (serotonin and norepinephrine reuptake inhibitor, a medication used to treat major depressive disorder, anxiety, and chronic nerve pain) and was used for depression or nerve pain. The pharmacist said duloxetine had a long half life so the drug stays in the system for a long time and that being late for a few hours should not affect the resident a lot. The pharmacist said aspirin was an antiplatelet that helped people prevent a clot from being formed. The pharmacist said the pharmacy was alerted about new medication requests or refills through the facility. The pharmacist said the facility normally requested a refill request via fax, phone call, or electronically. The pharmacist said once the pharmacy received the medication request they delivered the medication within one business day, The pharmacist said they provided three deliveries per day to the facility. The pharmacist said the last time the medications were requested and delivered was on 6/8/26. The pharmacist said the medications were also requested that morning on 6/25/26 and the medications were in route to be delivered to the facility.The director of nursing (DON) was interviewed on 6/25/26 at 5:09 p.m. The DON said that the three medications were not delivered by pharmacy yet. The DON said that eliquis was a blood thinner and it helped prevent blood clots from forming. The DON said that aspirin was used as a prophylactic medication that could have helped prevent strokes and pain. The DON said duloxetine was used for pain or depression. The DON said that Resident #50's duloxetine was ordered for neuropathy. The DON said that nurses should reorder medications. The DON said the nurses should have requested the medications 72 hours prior to running out of supply so that the facility did not run out of medication and so the resident did not go without medications. The DON said that eliquis and duloxetine were not present in the pyxis but that the facility was working to increase the medications available in the pyxis. The DON said if nurses did not have medications present in the medication cart, they should check their resources and emergency supplies. The DON said that nurses should notify the provider that they did not have the medication available and also let the family know. The DON said nurses should let her know if they did not have medications available to give residents so she could reach out to the pharmacy.

Based on observations, record review and interviews, the facility failed to ensure two (#58 and #70) of four residents reviewed received food and fluids prepared in a form designed to meet his or her needs out of 39 sample residents.Specifically, the facility failed to:-Ensure Resident #58 was served a mechanically altered diet per physician's orders; and,-Ensure Resident #70 received nothing by mouth (NPO) per physician's orders.Findings include:I. Professional referenceThe International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (atool to standardize mechanically altered diets and liquids) (January 2019), retrieved on 6/29/26from https://iddsi.org/Resources/Patient-Handouts read in pertinent part, Soft and bite sized foods: soft, tender and moist, but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is not required. Ability to chew bite-sized pieces so that they are safe to swallow is required. Bite sized pieces are no bigger than 1.5 centimeters (cm) by 1.5 cm in size. Food can be mashed/broken down with pressure from a fork. A knife is not required to cut this food. Level 6 - Soft and bite-sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft & bite-sized foods need a moderate amount of chewing, for the tongue to 'collect' the food into a ball and bring it to the back of the mouth for swallowing. The pieces are 'bite-sized' to reduce choking risk. If you notice the food pieces are not being chewed well though, please contact your clinician to make sure you are on the correct food texture to reduce choking risk. Soft & Bite-Sized foods are eaten using a fork, spoon or chopsticks. Avoid foods with skins or an outer shell, including peas. No regular dry bread due to high choking risk.II. Facility policy and procedureThe Texture and Consistency - Modified Diets policy and procedure, undated, was received from the nursing home administrator (NHA) on 6/25/26 at 5:29 p.m. It read in pertinent part, Texture and consistency-modified diets will be individualized with modifications made by the speech language pathologist (SLP) and physician in conjunction with the registered dietitian (RD) or designee and nutrition services director. The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered.III. Resident #58A. Resident statusResident #58, age [AGE], was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included metabolic encephalopathy (brain dysfunction), Parkinson's disease and convulsions.The 6/2/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision or touching assistance with eating.The assessment indicated the resident did not have signs and symptoms of a swallowing disorder and required a mechanically altered diet.B. Resident representative interviewResident #58's representative was interviewed on 6/24/26 at 9:07 a.m. The resident's representative said Resident #58 had been getting speech therapy as he had problems with chewing and swallowing. The resident's representative said the facility had to cut up Resident #58's food for him, but said they had not done that for a while. The resident's representative said Resident #58 had difficulty eating peas and rice due to his dexterity. The resident's representative said she had not heard from anyone at the facility about liberalizing Resident #58's diet, but said he usually got a regular plate which looked like everyone else's in the dining room.C. ObservationsOn 6/23/26 at 11:59 a.m., during the lunch meal service, Resident #58 was served a regular texture meal including a roll, a slice of cake, whole fettucini noodles with strips of chicken approximately two inches long and peas. Resident #58's meal ticket was observed and revealed the resident had a regular diet, regular texture. Resident #58 ate alone at his table without consistent, meaningful supervision from staff.On 6/23/26 at 5:32 p.m., during the dinner meal service, Resident #58 was served a regular diet meal including a key lime bar, roasted vegetables cut into one-inch pieces, breaded fried fish cut into one inch pieces, and potato wedges cut into 3/4 inch-sized pieces. Resident #58's meal ticket was observed and revealed the resident had a regular diet, regular texture. Resident #58 ate alone at his table without consistent, meaningful supervision from staff.-However, Resident #58's diet order was Level 6, soft and bite sized on 6/23/26 (see physician's order below).D. Record reviewThe nutrition care plan, initiated 6/22/26, revealed Resident #58 was at risk for alteration in nutritional status due to recovering from an acute illness, poor endurance and fatigue. Pertinent interventions included assessing oral and feeding status and arranging therapy as needed, and providing diet as ordered.Review of Resident #58's June 2026 CPO revealed the following orders:-Fortified regular diet, soft and bite sized texture (Level 6), thin liquids. Cut up all meats due to bilateral upper extremity weakness; deli/breakfast meat, fish, breads, hamburger patties okay whole per SLP, ordered 6/4/26;-May have regular texture diet per patient request, ordered 6/23/26 at 5:52 p.m. (during the survey); and,-Fortified regular diet, regular texture, thin liquids. Cut up chicken breast, pork chops, ham and steak per SLP, ordered 6/24/26 (during the survey).The speech therapy note, dated 5/26/26, revealed Resident #58 was assessed by the facility SLP. Resident #58's diagnoses included dysarthria (a motor-speech disorder) and oropharyngeal phase dysphagia. Resident #58 admitted to the hospital on [DATE] following an episode of reduced responsiveness at home. Resident #58 was seen by the SLP in the hospital and was referred for speech therapy in the facility for speech and dysphagia management. Clinical impressions on assessment revealed Resident #58 had moderate oropharyngial dysphagia characterized by difficulty with solids in oral phase and liquids in the pharyngial phase. The SLP recommended mechanical soft diet textures with close supervision while eating.-However, observations revealed the resident did not receive a mechanical soft diet texture or meaningful supervision while eating (see observations above).A nutritional assessment, dated 5/26/26, revealed Resident #58 was assessed by the dietary manager (DM). The assessment indicated Resident #58 knew what diet the physician had ordered and did not want his diet liberalized or changed. The assessment indicated Resident #58 was ordered to have a fortified regular diet, regular texture.-However, the facility SLP had recommended a mechanically altered diet texture per her evaluation notes on 5/26/26.A progress note, dated 6/17/26 at 1:49 p.m., revealed Resident #58 was reviewed for a nutritional follow-up by the dietitian. Resident #58 was receiving a fortified regular diet with a soft and bite-sized texture. A progress note, dated 6/23/26 at 9:25 a.m. (during the survey), revealed Resident #58 was assessed by his physician's assistant (PA). The PA's assessment notes revealed Resident #58 was reviewed and found to have concerns for dysphagia or slow swallow transit and was referred to the SLP.A written statement from the SLP, dated 6/24/26 (during the survey), revealed Resident #58 was admitted on [DATE] when his diet textures were modified by the SLP as appropriate for the resident in agreement with the resident himself. Resident #58 was compliant with his diet textures as ordered. There was no need, thus, for a refusal of treatment form to be signed.-However, Resident #58's modified texture diet order was changed to a regular texture per his or his representative's request (see interviews below).E. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 6/23/26 at approximately 11:59 a.m. CNA #4 said Resident #58 was on a regular diet texture with cut up meats. CNA #1 was interviewed on 6/23/26 at 1:28 p.m. CNA #1 said CNAs were responsible for passing out meal trays. CNA #1 said she did not look at the diet texture information on the meal ticket because she trusted the dietary staff to do that, and said she set up the resident's meal for them. CNA #1 said if she noticed a resident was served the wrong diet texture she would bring the meal ticket with her and talk to the kitchen about it. CNA #1 said if she saw a meal with the wrong diet texture she would leave the meal tray in the room with the resident while she spoke with the kitchen. CNA #5 was interviewed on 6/23/26 at 1:35 p.m. CNA #5 said whenever a new resident entered with an altered diet texture she received training on what to look for with their diet texture. CNA #5 said CNAs were responsible for passing out meal trays, and said she checked the resident's food texture to ensure it matched their diet order before serving it. CNA #5 said if she saw a resident was served the wrong diet texture she would take it back to the kitchen and take the tray with her while doing so.Cook #1 was interviewed on 6/23/26 at 1:55 p.m. [NAME] #1 said he had received training on the different diet textures on hire and annually. [NAME] #1 said food items for a soft and bite-sized diet needed to be smaller than the end of a fork and easy to mash. [NAME] #1 said the meal service process involved the cook serving the meal and the dietary aide at the kitchen window checked the meal to ensure what was served matched the resident's diet texture.Registered nurse (RN) #2 was interviewed on 6/23/26 at 2:27 p.m. RN #2 said Resident #58 was on a soft and bite-sized diet texture. RN #2 said Resident #58 had Parkinson's disease and dysphagia, and had been working with speech therapy. RN #2 said a resident on a soft and bite-sized diet could not have whole length pasta noodles.The dietary manager (DM) was interviewed on 6/23/26 at 2:53 p.m. The DM said meal ticket information was entered into their system and meal tickets were printed for the next day at the end of the night prior. The DM said he updated residents' diet textures as needed. The DM said he provided monthly trainings for the dietary staff members which covered different subjects, and said he had covered the different diet textures recently. The DM said whole spaghetti, linguini or fettuccini noodles would not be appropriate for a soft and bite-sized diet and would need to be chopped up. The DM said Resident #58 was on a soft and bite-sized diet with cut up meats, and could not have whole pasta noodles. The DM said their process for meal service was having the cook plate the meal, the dietary aide plate the dessert and check the diet texture, and the CNAs in the kitchen window and delivering the room trays were their final check. The director of nursing (DON) was interviewed on 6/23/26 at 5:39 p.m. The DON said Resident #58's diet may have been liberalized by the SLP or RD and the order was not put into his electronic medical record (EMR). The DON said the most updated diet order she saw in Resident #58's EMR was for a soft and bite-sized diet texture with whole breakfast patties and fish.The DON entered the dining room where Resident #58 was eating dinner (see observations above) and said the key lime bar and vegetables were definitely for a regular textured diet.The DON was interviewed a second time on 6/23/26 at 6:16 p.m. The DON said the SLP and Resident #58's physician had been in communication with Resident #58's representative regarding his diet texture and she or Resident #58 had requested a regular diet. The DON said she did not know if any diet waivers had been signed.-However, Resident #58's representative said no one from the facility had reached out to her regarding Resident #58's diet texture (see interview above).The SLP was interviewed on 6/24/26 at 8:40 a.m. The SLP said a soft and bite-sized diet texture was characterized by being a cut up diet which was not dry or crumbly. The SLP said Resident #58's representative said he had a lot of swallowing problems and had choked at home. The SLP said Resident #58 was on a soft and bite-sized diet at the time with a lot of exceptions, including whole fish and hamburger patties. The SLP said Resident #58 still had a soft and bite-sized diet as of the last time she worked with him in speech therapy four days prior. The SLP said the residents' medical providers could make changes to residents' diet orders without consulting her but it was almost unheard of. The SLP said she had not been working with Resident #58 to advance his diet texture to regular. The SLP said Resident #58 did have a diagnosis of dysphagia and said that diagnosis should be listed in his EMR.The RD was interviewed on 6/24/26 at 10:16 a.m. The RD said when a new resident was admitted , the admission nurse had a diet communication sheet with diet orders at the top, which was then given to the DM or the kitchen staff. The RD said the DM would enter the resident's diet information into their meal ticket software and update it as needed. The RD said she told the kitchen staff to refer to the IDDSI extension sheets to see what was and what was not allowed for each diet texture. The RD said soft and bite-sized diets should be soft foods cut to the size of the end of a fork. The RD said long pasta noodles would not be acceptable for a soft and bite-sized diet. The RD said Resident #58 had orders for a soft and bite-sized diet but had been working with the SLP so there were more items allowed back into his diet. The RD said if Resident #58 refused a soft and bite-sized diet and it was unsafe for him to have a regular diet he would need a diet texture waiver, but said she would want the SLP to evaluate him again before doing so. The RD said she usually provided education to the resident and their representative prior to doing a diet texture waiver as well.The DON and the nurse manager were interviewed together on 6/24/26 at 2:00 p.m. The DON said Resident #58 would say he did not have any chewing or swallowing problems. The DON said she was not sure if he was just eating too fast and the SLP was concerned he was going to choke so she downgraded his diet texture. The DON said she thought Resident #58's diet never should have been downgraded from regular texture. The DON said she did not think Resident #58 had any diagnoses or issues with dysphagia, and said the SLP said he may have had some issues with aspiration in the past. The DON and the nurse manager said they had spoken with the SLP about making her diet orders more clear, which was why Resident #58's diet order had been changed the day prior (6/23/26). The nurse manager said she had provided the SLP with education, since her diet order recommendations needed to be all or nothing.The nurse manager said the SLP recommended a regular diet for Resident #58 if he was sitting with his friends, and said he was otherwise cleared to have some breads and uncut meats. -However, Resident #58's physician ordered diet was a Level 6 soft and bite sized diet and specified the resident could have certain meats or bread whole. The order did not specify any modifications that could be made depending on the level of supervision Resident #58 had any company with him at the dining table (see record review above).The DON and the nurse manager said the CNAs in the kitchen window and the CNAs passing out room trays were the third and fourth checkers to ensure residents received the correct texture diet, and said the CNAs should check the meals prior to serving to ensure they were correct. The DON and the nurse manager said the nursing staff should not leave a meal tray in the room with the resident if they needed to clarify which diet texture the resident should have received.IV. Resident #70A. Resident statusResident #70, age [AGE], was admitted on [DATE] and discharged to the hospital on 6/21/26. According to the June 2026 computerized physician orders (CPO), diagnoses included encephalopathy, intracerebral hemorrhage (a type of stroke caused by a ruptured blood vessel within the brain), pneumonitis due to inhalation of food or vomit and dysphagia.An admission assessment, dated 6/19/26, revealed the resident was disoriented and usually able to make himself understood and understand others. The assessment documented the resident had a percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) in place.B. Record reviewHospital discharge notes, dated 6/19/26, revealed Resident #70 had a PEG tube placed on 6/16/26 for enteral feeding given persistent oropharyngeal dysphagia. Resident #70 was NPO per the hospital SLP but was okay to have limited ice chips with supervision and oral care provided afterwards. Resident #70's bed was to be kept elevated at a 45 degree angle or higher given his high risk of aspiration. Resident #70 would likely depend on tube feedings for the foreseeable future.Review of the July 2026 CPO revealed a diet order for NPO and tube feedings, ordered 6/20/26.An admission note, dated 6/19/26 at 6:18 p.m., revealed Resident #70 admitted to the facility from an acute care hospital that day (6/19/26) at 4:30 p.m Resident #70 was not verbally responsive toward staff but did speak and answer to his wife, who was present at bedside during admission. Resident #70 would need frequent checks as he had mild confusion and attempted to ambulate when he needed to use the restroom.A progress note, dated 6/19/26 at 6:50 p.m., revealed registered nurse (RN) #1 entered Resident #70's room to see if his enteral feeding was set up. Resident #70 was supposed to be NPO according to the ticket on his room tray but Resident #70 had in front of him an intact plate of food and a glass that contained juice was empty. RN #1 asked Resident #70 if he drank the juice, but the resident did not respond. RN #1 removed the meal tray and noted the resident did not appear to be in distress at the time. Resident #70's physician was notified.A progress note, dated 6/19/26 at 8:15 p.m., revealed licensed practical nurse (LPN) #1 entered Resident #70's room to assist RN #1 with setting up the resident's enteral feed. LPN #1 saw Resident #70 had an empty glass and plate of food in front of him. LPN #1 said Resident #70 was NPO, and RN #1 looked at the meal ticket in front of Resident #70 which said NPO. The tray was removed from Resident #70's room and LPN #1 instructed RN #1 to contact Resident #70's physician. LPN #1 set up Resident #70's enteral feed and alerted the administration.A progress note, dated 6/20/26 at 9:41 a.m., revealed LPN #1 notified Resident #70's physician about the resident receiving fluids. Resident #70's vital sign measurements were elevated that morning, with his pulse at 106 beats per minute, oxygen saturation of 89% and a fever of 101.2 degrees Fahrenheit (F).A progress note, dated 6/20/26 at 11:07 a.m., revealed Resident #70 was sent to the hospital per his physician. Resident #70 was given liquids during the night shift on 6/19/26. Resident #70 was running a fever of 102.9 degrees F and had an elevated pulse. Resident #70 was transferred via ambulance to the emergency room.A new admission nutrition services review form, dated 6/20/26, revealed Resident #70 had orders to have tube feedings. The form indicated the RD did not need to immediately assess Resident #70, and was completed on 6/20/26.-However, the form did not document Resident #70 was NPO.C. Staff interviewsCNA #1 was interviewed on 6/23/26 at 1:28 p.m. CNA #1 said if a resident had an order to be NPO, that meant they could not eat or drink anything by mouth.The DM was interviewed on 6/23/26 at 2:53 p.m. The DM said residents who were NPO would not get a meal tray. The DM said depending on the physician's orders the resident may be okay to have ice chips, but that would be resident-dependent. The DM said the night Resident #70 had admitted the admission nurse had written a diet slip and was working to determine if the resident was NPO. The DM said he believed Resident #70 had a diet slip that said he was NPO and had a diet texture, which was why he received a room tray that evening. The DM said he and the nursing staff clarified with the dietitian afterward to determine he was NPO. The DM said he had not done any reeducation on NPO status for residents.The SLP was interviewed on 6/24/26 at 8:40 a.m. The SLP said she worked collaboratively with the RD and the resident's physician whenever a resident admitted NPO. The SLP said when Resident #70 entered she had checked with the admitting nurse to see if he needed to be evaluated that day or if her evaluation could wait until the following week, and the nurse responded by saying it was okay for the evaluation to wait until the following week. The SLP said a meal tray would not have been appropriate for Resident #70 since he was NPO. The SLP said the process for reintroducing an oral diet required physician's orders and SLP evaluations. The SLP said she thought Resident #70 getting a room tray while being NPO was a mistake from the floor nursing staff or the CNAs who thought they just had a newly admitted resident who needed a tray.The RD was interviewed on 6/24/26 at 10:16 a.m. The RD said if a resident had orders for enteral nutrition she was usually notified fairly quickly by the nursing staff, and their diet order should be marked NPO so the kitchen did not prepare a meal tray for the resident. The RD said Resident #70's diet communication sheet had been handed to the kitchen staff when it should have been handed to the DM since a meal tray did not need to be made. The RD said she did not know why or how Resident #70 was served a meal tray. The RD said serving a meal tray to a resident with dysphagia who had orders to be NPO could put the resident at risk of choking or potentially death.The DON and the nurse manager were interviewed together on 6/24/26 at 2:00 p.m. The DON said she was not at the facility when Resident #70 arrived. The DON said with newly admitted residents, the nursing staff reviewed the hospital discharge orders and filled out a diet communication form which was then given to the DM or the kitchen staff. The DON said Resident #70 was NPO and received enteral nutrition. The DON said the admission nurse filled out the diet communication form and gave it to the kitchen staff. The DON said she was informed Resident #70 had received a room tray and there was an empty cup on the tray, but no one witnessed Resident #70 have any intake by mouth. The DON said all of the nursing staff present at the time had been informed Resident #70 was NPO, and said she was not sure why he got a meal tray. The DON said the facility staff's assumption was that Resident #70 did drink from the glass on the tray, but said the physician reviewed his most recent hospital notes and did not see any significant changes in their diagnostics from his last hospitalization. The DON said Resident #70 was going to return to the facility after his hospitalization. The DON said when Resident #70 returned she would put signs up indicating he was NPO, and said the RD had provided education to all nursing and dietary staff on what NPO meant.VI. Staff educationEducation regarding diet textures was provided by the NHA on 6/24/26 at 4:06 p.m. (during the survey process) and revealed the following:LPN #1 received education on 6/24/26 which identified she did not follow the admission process as required, and specifically failed to clarify an NPO diet order for the dietary staff. The failure to complete the process may have resulted in inaccurate dietary orders and possible harm to the resident. LPN #1 was expected to physically write down NPO on a diet order sheet and obtain signs which indicated the resident was NPO to hang in their room.Education was provided to ten members of the nursing staff on 6/24/26 related to the different IDDSI diet texture levels, including what they were supposed to look like and what each diet level could not have.Education was provided to CNA #1 on 6/24/26 on the importance of verifying resident diet orders and meal tickets before delivering meal trays, and incorrect meal trays being removed from residents' rooms immediately and not left at their bedside. The education noted when residents received food not consistent with their prescribed diet order, there was an increased risk of choking, aspiration, aspiration pneumonia, blood sugar fluctuations, allergic reactions, or even death.Education was provided to four of 14 members of the dietary staff on 6/24/26 about the minced and moist and the soft and bite-sized IDDSI diet textures.-However, this education was provided on 6/24/26, five days after Resident #70 was served a meal despite a physician's order to be NPO. Additionally, the facility did not provide record of any training materials for the dietary staff on NPO resident orders.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards in one out of three medication carts. Specifically, the facility failed to ensure the medication cart was locked when not in the direct line of sight of a nurse. Findings include:I. Facility policy and procedureThe Medication storage policy, revised September 2022, was provided by the director of nursing (DON) on 11/20/25 at 2:40 p.m. It read in pertinent part, Only licensed nurses and pharmacy personnel are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. II. ObservationsMedication cart #5 was observed on 11/19/25 at 1:26 p.m. with registered nurse (RN) #2. RN #2 walked up to the medication cart by the nurses' station and tugged on the top drawer which opened. She pushed the drawer back and pushed the lock in with her hand locking the cart. She said the cart was not locked correctly and the cart should be locked at all times. Medication cart #5 was observed on 11/19/25 at 2:18 p.m. The cart was unlocked and unattended. There were residents and housekeeping personnel around the medication cart. The medication cart was by the nurses' station. There was one unidentified staff member sitting at the station facing a computer screen. He was sitting with his back to the cart. At 2:21 p.m. RN #3 walked up to the cart. RN #3 opened and closed a drawer then he charted on the screen. After charting, he walked across the nurses' station leaving the cart unlocked. He returned to the cart at 2:27 p.m. when he locked the cart by pushing the locking mechanism in. III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 11/19/25 at 2:54 p.m. LPN #2 said medication carts should be locked when unattended for the safety of others. She said it was a crucial part of the job to keep medication locked. She said it was important since there was heavy traffic in the hallway from visitors, residents, and staff members She said the staff were trained quarterly on safe medication storage. RN #3 was interviewed on 11/20/25 at 1:21 p.m. RN #3 said he always made sure that the cart was locked. He said he made sure that the lock on the medication cart was pressed in so it was locked. He said he would tug on the drawers to make sure that the cart was locked. He said that the medication cart should have not been left unlocked.The DON was interviewed on 11/20/25 at 1:45 p.m. She said medication carts should not be left unlocked and unattended. She said it was the facility`s policy to keep the medications locked at all times.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure the residents were offered hand hygiene before meals in the dining room and during the delivery of room trays; and, -Ensure point of care (POC) testing supplies were not contaminated from room to room. Findings include: I. Failed to ensure hand hygiene was offered to residents prior to meals A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Hand Hygiene in Healthcare settings, revised 2/27/24, was retrieved on 10/28/24 from https://www.cdc.gov/handhygiene/index.html Patients and visitors should clean their hands before preparing or eating food. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics, and protects healthcare personnel and patients. Using an alcohol-based hand sanitizer is the preferred way for you to keep your hands clean. B. Facility policy and procedure The Dining Experience policy, revised January 2021, was provided by the nursing home administrator (NHA) on 10/22/24 at 4:16 p.m. It read in pertinent part, Individuals will be provided with proper hand hygiene prior to each meal or snack, prepared for the meal by the nursing staff (hearing aids in place, dentures in, hair combed, dressed properly, and eyeglasses on); and assisted to the dining area as needed. C. Observations On 10/21/24 during a continuous observation, beginning at 11:40 a.m. and ending at 1:20 p.m., residents arrived for lunch in the main dining room, some walking in, some self-propelling themselves in manual wheelchairs and some escorted in by staff. Resident #13, #22, #44 and #65 in wheelchairs were handling the large wheel on their manual wheelchairs to propel themselves into the dining room. Residents were assisted to sit at their tables by staff in the dining room. Tables in the dining room had multiple residents sitting together. Of all the residents in the dining room (28 total residents), none were offered or assisted with hand hygiene. On 10/21/24 at 12:46 p.m., CNA #1 delivered a room tray to room [ROOM NUMBER]. At 12:47 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 12:48 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 12:50 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 12:51 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 12:53 p.m. a meal tray was delivered to room [ROOM NUMBER]. -There were no individual hand sanitizing packets on the room trays and CNA #1 did not ask, encourage or assist any of the residents with washing or sanitizing their hands before the meal.Additional meal tray observations: On 10/21/24 at 12:48 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 12:49 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 12:51 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 1:00 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 1:01 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 1:02 p.m. a meal tray was delivered to room [ROOM NUMBER]. At 1:06 p.m. a meal tray was delivered to room [ROOM NUMBER]. -Staff did not encourage or assist residents with hand hygiene. D. Resident interviews Resident #49 was interviewed on 10/21/24 at 11:59 a.m. Resident #49 said the staff had never offered hand sanitizer or to wash his hands in the dining room. Resident #7 was interviewed on 10/21/24 at 1:20 p.m. Resident #7 said the staff did not offer hand hygiene prior to her meal on this day (10/21/24). E. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 10/21/24 at 1:06 p.m. CNA #1 said she had not offered hand hygiene to the residents who ate independently during the lunch meal. CNA #2 was interviewed on 10/21/24 at 1:11 p.m. CNA #2 said he did not offer hand hygiene to any residents in the dining room prior to the lunch meal. He said all residents should be offered hand hygiene prior to meals. The director of nursing (DON) was interviewed on 10/21/24 at 4:42 p.m. The DON said hand hygiene should be offered to residents prior to meals in the dining room or the resident rooms, regardless of whether the resident was independent with self-care. II. Failed to ensure point of care testing supply was not contaminated A. Professional reference According to Agency for Healthcare Research and Quality's Clean Equipment and Environment Promotes Safe Resident Care, revised March 2017, was retrived on 10/28/24 from https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/environment-and-equipment/environ-equip-slides.htmlInfectious agents, like bacteria or viruses can move from one person to the next and possibly spread throughout an entire facility. They are transmitted by our hands, a contaminated surface or a piece of equipment that is used between residents. B. Observations On 10/23/24 at 11:52 a.m. licensed practical nurse (LPN) #2 placed blood sugar testing supplies which included test strips, lancets and alcohol wipes in a disposable plastic 120 milliliter (ml) cup. LPN #2 brought the cup to room [ROOM NUMBER] and placed it on the resident's dining table. LPN #2 then used supplies from the cup to test the resident's blood sugar. At 12:08 p.m. LPN #2 brought the same disposable cup with remaining testing supplies from room [ROOM NUMBER] to room [ROOM NUMBER] and placed the cup on the resident's dining table. She used the supplies from the cup to test the resident's blood sugar. At 12:18 p.m. LPN #2 placed the disposable cup with remaining supplies in the top drawer of the hall #3 medication cart. At 12:24 p.m. LPN #2 removed the disposable cup from the top drawer of the hall #3 medication cart and used the remaining supplies to test Resident #65's blood sugar while he was sitting in the hallway. C. Staff interviews LPN #2 was interviewed on 10/23/24 at 12:08 p.m. LPN #2 said she should not have brought the disposable plastic cup with testing supplies from room to room and back to the medication cart as this could spread infection. The DON was interviewed on 10/23/24 at 12:45 p.m. The DON said LPN #2 should have brought enough testing supplies for each individual resident to each resident. The DON said it was inappropriate to use the disposable cup with testing supplies for multiple rooms/residents as it was an infection risk. D. Facility follow up On 10/23/24 at 1:26 p.m. the DON provided documentation for education provided to LPN #2 which included the requirement to utilize POC supplies for one resident (not sharing supplies for multiple residents).

Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were provided in order to to attain the resident's highest practicable physical, mental, and psychosocial well-being and to provide effective and person-centered care for three (#4, #11 and #26) of 13 residents out of 37 sample residents. Specifically, the facility failed to: -Ensure the comprehensive care plan addressed Resident #4's pressure ulcer; -Ensure the comprehensive care plan addressed Resident #11's changes related to her feeding tube, diet, intravenous (IV) antibiotics and fall interventions; and, -Ensure the comprehensive care plan addressed Resident #26's pressure ulcer. Findings include: I. Facility policy and procedure The Care Planning policy, undated, was provided by the nursing home administrator (NHA) on [DATE] at 9:16 a.m. It read in pertinent part, The facility will develop a comprehensive person-centered care plan following the most current regulatory requirements available. The care plan should be based on patient strengths and preferences, be oriented toward avoiding preventable declines in functioning, and reflect current standards of care in professional practice. The care plan should be evaluated to determine if current interventions are being followed and if they are effective in attaining identified goals and the care plan should be modified as needed. Subsequent adjustment of interventions will depend on progress, underlying causes and overall condition. Modify the current care plan and add new or additional interventions as needed. II. Resident #4 A. Resident status Resident #4, age above 65, was admitted on [DATE] and discharged on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic kidney disease, osteoarthritis (degenerative joint disease), glaucoma (chronic eye disease causing damage to the optic nerve and vision loss), and right knee effusion (fluid buildup and swelling). The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #4 was dependent on staff for transfers, required substantial assistance with bed mobility and used a wheelchair for mobility with substantial assistance from staff. She had one unstageable pressure injury present on admission. B. Resident interview Resident #4 was interviewed on [DATE] 3:36 p.m. She said she had a wound on her right heel and she wore a soft heel protecting boot when she was in bed. C. Record review The skin integrity care plan, initiated [DATE], indicated Resident #4 had a deep tissue injury to her left buttock and a stage one pressure injury to her spine. Interventions included notifying the provider of any changes, offloading the area as tolerated, completing weekly skin checks, and providing supplements, medications and treatments as ordered. The skin assessment note, dated [DATE], revealed Resident #4 had a deep tissue injury to her right heel. -Review of the comprehensive care plan did not reveal the care plan had been updated to indicate that Resident #4 had a deep tissue injury to her right heel. -The care plan did not include the intervention of the soft heel protecting boot (see interviews below). D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 9:14 a.m. LPN #1 said Resident #4 had a wound on her right heel and wore a soft boot for protection while in bed. The director of rehabilitation (DOR) was interviewed on [DATE] at 10:25 a.m. The DOR said she provided the soft heel protector for Resident #4 to wear while in bed or when up in her wheelchair when requested. The infection preventionist (IP) #2 was interviewed on [DATE] at 8:19 a.m. IP #2 said she was the wound care nurse. She said the pressure injury should have been included in Resident #4's care plan and the soft heel protector listed as an intervention. III. Resident #11 A. Resident status Resident #11, age 85, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included sepsis (extreme reaction to an infection), acute respiratory failure with hypoxia (low oxygen in the body), chronic obstructive pulmonary disease (a common lung disease causing difficulty breathing), pneumonia, congestive heart failure (chronic condition when the heart cannot pump enough blood to the body), dysphagia (difficulty swallowing), asthma (inflammation an tightening of airway muscles causing difficulty breathing) and glaucoma (high eye pressure). The [DATE] MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of eight out of 15. Resident #11 was dependent on staff for all activities of daily living (ADLs). The MDS assessment indicated the resident was receiving all nutrition, liquids and medication through a feeding tube and was receiving intravenous (IV) antibiotics. B. Resident interview Resident #11 was interviewed on [DATE] 2:46 p.m. Resident #11 said she had made a significant improvement since her admission. She said she was eating orally now and no longer needed the feeding tube. She said her IVs were stopped. She said she had a fall at the facility where she sustained facial injuries. She said she did not recall any interventions the facility implemented after the fall. C. Record review The feeding tube care plan, initiated on [DATE], included interventions to aspirate the feeding tube for residual prior to feeding, confirm placement of the tube by inserting a small amount of air prior to feeding, elevate the head of the bed during feedings and 30 minutes after, administer feeding solution per physician order and administer medication per tube. A review of the [DATE] physician orders revealed the resident's diet order was strict NPO (nothing by mouth). A review of the September physician orders revealed the resident began taking food by mouth on [DATE]. A pureed diet for lunch and dinner was ordered on [DATE]. A minced and moist diet was ordered on [DATE] for all three meals. The physician progress note dated [DATE] revealed the feeding tube was discontinued on [DATE]. -The comprehensive care plan was not revised to indicate Resident #11 was taking food by mouth, the feeding tube was discontinued or what type of diet was ordered. The IV antibiotic care plan, initiated on [DATE], included interventions to keep the IV site patent and free of infection, change tubing and caps per protocol, perform dressing changes and site care per protocol, flush per protocol and administer medication as ordered. A review of the September physician orders revealed the IV antibiotics were discontinued on [DATE]. -The comprehensive care plan was not revised to indicate the resident was no longer receiving IV antibiotics. The nursing progress notes indicated Resident #11 had an unwitnessed fall on [DATE]. A review of the post fall IDT progress note dated [DATE] revealed a non-skid surface to Resident #11's wheelchair was implemented for fall prevention. The note indicated the care plan was updated. -However, the fall care plan was not updated to include the recent fall or the new intervention of the non-skid surface in the wheelchair. D. Staff interviews Certified nurse aide (CNA) #5 was interviewed on [DATE] at 10:00 a.m. CNA #5 said she did not think Resident #11 was a fall risk. CNA #5 said the resident had one fall but had improved since then. CNA #5 said she was not aware of any fall prevention interventions that were implemented after the fall. The registered dietitian (RD) was interviewed on [DATE] at 2:50 p.m. The RD said when there was a diet change the nutrition care plan should be updated with the diet order and interventions. The RD said she put her updates in the nutrition assessment section. She said the nutrition team meeting notes were sent to the MDS coordinator so they could update the comprehensive care plan. The director of nursing (DON) was interviewed on [DATE] 11:14 a.m. The DON said fall interventions should be listed on the care plan. The DON Resident #11's feeding tube and IV antibiotic care plans should have been resolved and her nutrition care plan updated. IV. Resident #26 A. Resident status Resident #26, age 97, was admitted on [DATE] and expired on [DATE]. According to the [DATE] CPO, diagnoses included congestive heart failure, hypertensive heart disease, major depressive disorder, polycythemia vera (blood cancer causing bone marrow to produce too many red blood cells) and encephalopathy (unspecified condition causing brain dysfunction). The [DATE] MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of four out of 15. Resident #26 required substantial assistance from staff for all ADLs. B. Record review The baseline care plan, dated [DATE], documented the resident had a pressure injury on the sacrum (the bone at the base of the spine above the coccyx). The comprehensive care plan, skin section, initiated on [DATE], indicated Resident #26 had an alteration in skin integrity consisting of blanchable red (redness of skin that temporarily disappears with light pressure) ears and coccyx. Interventions included notifying the provider of any changes, offloading the area as tolerated, completing weekly skin checks and providing supplements, medications and treatments as ordered. -The comprehensive care plan did not indicate the presence of a pressure injury to the sacrum. The [DATE] wound physician (WP) note revealed Resident #26 had a stage IV pressure injury to the sacrum. The WP provided treatment orders and instructed staff to turn the resident from side to side in bed every one to two hours. -The comprehensive care plan was not updated to include the stage IV pressure injury and did not include the WP's treatment orders or recommendation for turning. C. Staff interviews The DON was interviewed on [DATE] 11:14 a.m. The DON said each discipline updated their own section of the care plan. The DON said care plans should be updated when there were any changes in a resident's care. The DON said the pressure injury should have been included in Resident #26's comprehensive care plan.

Based on observations, record review, and interviews, the facility failed to ensure proper storage of medications in the medication storage room and in one of three medication storage carts. Specifically, the facility failed to: -Discard medications from the medication cart that had been discontinued; -Remove loose pills from drawer of a medication cart; and, -Ensure the temperature of the medication refrigerator was assessed, documented and addressed as needed. Findings include: I. Facility policy and procedure The Medication Storage policy, revised September 2021, was provided by the nursing home administrator (NHA) on 10/21/24 at 6:06 p.m. The policy, in pertinent part, contained the following information: -Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. All drugs and biologicals are in locked compartments under proper temperature controls. Medications requiring refrigeration, or temperatures between 36 degrees and 45 degrees Fahrenheit (F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Refrigerator temperatures are monitored twice daily and recorded in the Refrigerator Temperature Log Book. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. II. Observations and interviews On 10/21/24 at 10:18 a.m. the medication storage cart in hall #1 was observed with licensed practical nurse (LPN) # 1. The following was observed: -An open Fluticasone and Salmeterol 232 microgram (mcg)/14 mcg inhaler labeled with Resident #11's name. LPN #1 said the medication had been discontinued on 8/13/24 and should have been discarded after the physician's order was discontinued. -Four loose pills were in the bottom of the second drawer of the medication cart. LPN #1 said the loose pills needed to be discarded and was unsure of what the pills were. On 10/21/24 at 10:40 a.m. the medication storage room was observed with registered nurse (RN) #1. The following was observed: The August 2024 (8/1/24 to 8/31/24) medication refrigerator temperature log was missing documentation that indicated the temperature was taken on 13 days (8/11, 8/12, 8/13, 8/17, 8/18, 8/19, 8/20, 8/21, 8/25, 8/26, 8/27, 8/28 and 8/31/24). The medication refrigerator temperature was documented on 8/15/24 as 48.2 degrees F. The medication refrigerator temperature was documented on 8/16/24 as 51.6 degrees F. -There were no documented interventions for the temperature readings above 46 degrees F. The September 2024 (9/1/24 to 9/30/24) medication temperature log was missing documentation that indicated the temperature was taken on 17 days (9/2, 9/3, 9/4, 9/8, 9/9, 9/10, 9/11, 9/15, 9/16, 9/17, 9/18, 9/23, 9/24, 9/25, 9/28, 9/29 and 9/30). The October 2024 (10/1/24 to 10/21/24) medication temperature log was missing documentation that indicated the temperature was taken on 14 days (10/1, 10/2, 10/7, 10/8, 10/9, 10/12, 10/13, 10/14, 10/15, 10/16, 10/18, 10/19, 10/20 and 10/21). RN #1 said the temperatures should be checked and logged each day. RN #1 said the temperatures on 8/15/24 and 8/16/24 were abnormal. She said there was not a way to know the medication refrigerator temperature on the days that was no documentation. RN #1 said the nurses were responsible for checking the temperatures. She said she had noticed the weekend nurses had not been documenting them. III. Additional staff interviews The director of nursing (DON) was interviewed on 10/21/24 at 4:40 p.m. The DON said medications should be removed from the medication cart on the same day they were discontinued. The DON said the medication refrigerator temperatures should be checked daily and abnormal temperatures reported and addressed. IV. Facility follow up On 10/24/24 at 7:27 a.m. the DON provided a staff education document titled Medication Storage Policy and Procedure/ Medication Room/Both Refrigerator Temperatures. The education contained 10 staff signatures and was dated 10/22/24 (during the survey). The education content included a review and copy of the entire medication storage policy and stated expectation for staff to check refrigerator temperature every shift and document the temperature readings in the temperature book and to remove medications from the medication cart within 24 hours of discontinued physician order. The DON also provided a new form titled medication room temperature log which had entries for twice daily monitoring of medication refrigerator temperatures, with the normal ranges included. The form also had a statement, If temperature outside approved ranges, must notify DON and maintenance.

Based on record review and interviews, the facility failed to provide adequate supervision and an environment as free from accidents hazards as possible for one (#7) of three residents reviewed for accidents out of 27 sample residents. The facility failed to ensure proper transfer procedure was completed by staff to prevent a fall with injury for Resident #7. Resident #7, who had a diagnosis of medically complex conditions, was admitted to the facility on [DATE]. The facility failed to follow safety measures during resident transfers. The facility failed to provide two person assistance with transfers as documented in the 3/2/23 baseline care plan dated and the 3/7/23 minimum data set (MDS) assessment. Due to facility's failure to provide two person assistance with transfers and adequate supervision for transfers for Resident #7, she had a fall on 3/6/23 when transferring from the bed to wheelchair resulting in her being sent to the hospital for a head laceration requiring two sutures. Furthermore, the facility did not provide proper transfer education with staff after the incident on 3/6/23. Findings include: I. Facility policy The Fall Prevention policy, revised on 9/28/22, received from the nursing home administrator (NHA) on 5/9/23 at 11:52 a.m. It revealed in pertinent part, to ensure optimal patient safety, safety interventions will be implemented and monitored with appropriate documentation. The admitting nurse/nurse manager will be responsible for ensuring that interventions were initiated and communicated with staff to follow through. II. Resident #7 A. Resident status Resident #7, age 80, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnosis included pneumonia (lung infection), sepsis (systemic infection), urinary tract infection (infection in the bladder), type two diabetes (abnormal insulin levels), lymphedema (abnormal drainage on lymph nodes resulting in swelling) and hypertension (high blood pressure). The 3/7/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive two person physical assistance for transfers and bed mobility. One person extensive assistance with toileting and personal hygiene. She required set up assistance with eating. B. Resident and representative interview Resident #7 was interviewed on 5/4/23 at 10:20 a.m. She said she fell in the facility and hit her head on the bedside table or wall, which cracked her head open. The facility sent her to the emergency room and they stitched my head up. She said she was admitted to the hospital for her head injury along with pneumonia they found during testing. She said she was in the hospital for three weeks before coming back to the facility. Resident #7 was interviewed again on 5/9/23 at 2:00 p.m. She said she had only been in the facility a few days when she fell . She stated there was only one certified nurse aide (CNA) in the room transferring her from one place to another. When transferring from the bed to the wheel chair when she lost her balance and fell hitting her head. There was only one CNA in the room and there was not a gait belt on. Resident #7 stated her head was covered with blood and they sent her to the hospital via ambulance. Resident #7 said she needed two people for transfers because she was weak and scared to fall. Resident #7's son was interviewed on 5/9/23 at 2:30 p.m. He said the facility informed him of his mother's fall the day it happened. He was told she was transferring from the bed to the wheel chair with one person's assistance when she lost her balance and fell . He was told the CNA was standing in front of Resident #7 at the time of fall. He stated his mother required two person assistance at the time of the fall related to weakness. She was transported to the hospital due to the head injury she sustained during the fall. She stayed in the hospital for a few weeks because when they were conducting testing they also found her to have pneumonia. C. Record review The admission nursing observation dated 3/2/23 revealed Resident #7 had faint pedal pulses, bilateral lower extremity pitting edema, urinary incontinence due to the inability to reach the toilet timely related her to decreased mobility. The fall risk section of observation tool revealed Resident #7 had decreased muscular coordination, requiring use of assistive devices. The baseline person centered care plan dated 3/2/23 received from the NHA on 5/8/23 at 11:23 a.m. revealed Resident #7 required two person assistance with transfers, weight bearing as tolerated and no other safety measures were implemented on admission. The care plan dated 4/3/23 identified potential for complications related to recent fall with scalp laceration. Goal was to decrease the potential risk for falls during the duration of the residents stay. Interventions placed per care plan effective date 4/3/23 were to educate the patient on: high low bed to decrease risk of injury, notify physician, physical and occupational therapy. Resident #7 needs identified were gait training and strengthening with physical therapy (PT) and occupational therapy (OT). The PT evaluation note from 3/3/23 revealed Resident #7 was a modified assistance with staff performing 50% assistance with transfers. The OT evaluation dated 3/3/23 revealed resident was minimum to maximum assistance with transfers. On 3/6/23 at 10:22 a.m. a registered nurse (RN) documented she went to assist a certified nurse aide (CNA) who requested assistance with Resident #7 as she was slipping out of her recliner. The resident almost had a fall on the floor when the CNA, the RN and a physical therapy assistant (PTA) assisted the resident back into the recliner. The resident was unable to provide any assistance to get her back in the chair. The resident reported she was sitting in the recliner and began sliding forward to grab something causing the foot rest to tip the recliner chair forward. On 3/6/23 at 8:03 p.m. the RN documented Resident #7 had a witnessed fall in her room. The nurse assessment revealed the resident sustained a laceration to the back of the head. The resident was alert, vitals signs and all extremities found to be baseline. The resident denied pain. The resident was sent out to the emergency room for evaluation. On 3/6/23 at 10:12 p.m. the licensed practical nurse (LPN) note revealed around 7:20 p.m. the resident had a witnessed fall. The CNA stated the resident fell while she was transferring from the bed to the wheelchair, the resident lost her balance and fell backwards. The LPN requested an RN for assessment. The resident sustained a head laceration injury and was alert till she was transferred to hospital. Fall incident event, risk observation and care plan update dated 3/6/23 provided by the NHA on 5/9/23 at 11:23 a.m. revealed Resident #7 had a witnessed fall in her room while transferring with CNA present. She lost her balance and fell backwards. The resident hit her head on the wall and sustained a laceration to her head. She was transferred to the hospital. Fall observation post fall revealed the resident was alert and oriented to person, place and time. Indicated the resident had one to two falls in the past three months, adequate visions, regularly continent, balance problems with standing/walking, taking antihypertensive medication, predisposing diseases of hypotension. Evaluation concluded resident fall risk score of seven which placed resident in the low fall risk category. Care plan update two person assist for all transfers was selected. -Two person assist with transfers was already indicated staff failed to implement a new intervention for fall prevention post fall. Admission records dated 3/6/23 from the hospital indicated Resident #7 was admitted to the hospital for a fall with head laceration. The resident presented in the emergency department with significant scalp bleeding. The resident required two nylon sutures to control bleeding. CNA task documentation in point of care (POC) revealed the following for staff assistance with transferring: On 3/3/23 transfers were one to two person physical assistance; On 3/4/23 transfer were one person physical assistance; On 3/5/23 transfers were one person physical assistance; On 3/6/23 transfers were one person physical assistance; On 3/27/23 readmission transfers were two person physical assistance; and, On 3/28/23 transfers were one to two person physical assistance. -The documentation on 3/6/23 when the resident had a fall (see below) indicated the staff only had one person assisting the resident. III. Staff interviews The transition nurse (TR) was interviewed on 5/9/23 at 11:08 a.m. She said she assisted Resident #7 on 3/6/23 when she was slipping out of the recliner after reaching for something. She said Resident #7 was only given verbal education on recliner function/safety and no other interventions were implemented since she physically did not reach the floor. The director of nursing (DON), assistant director of nursing (ADON) and the regional director of nursing (RDON) were interviewed on 5/9/23 at 11:10 a.m. They acknowledged that the 3/6/23 MDS assessment indicated Resident #7 was a two person physical assistance with transfers. The DON verbalized the following for proper transfer technique for staff: a gait belt should be placed on the resident, the CNA should be standing behind the resident to support them once the resident was standing with balance and have a hold of the gait belt. She acknowledged Resident #7 fell backwards indicating the CNA was not behind the Resident #7 at the time of the fall. The DON provided documentation on 5/9/23 at 1:26 p.m. for a disciplinary action the CNA received from the facility post Resident #7 fall for failure to provide care with a secondary staff member for a resident who required two person assistance with transfers since admission. The statement provided by the CNA revealed she was assisting Resident #7 with a transfer from the bed to the wheel chair to go to the restroom. The CNA stated she was standing behind the resident during the transfer. -However, nursing documentation revealed Resident #7 fell backwards indicating CNA was not behind the resident. The DON was interviewed on 5/9/23 at 2:39 p.m. She said Resident #7's initial admission fall assessment on 3/2/23 fall score was four indicating she was at low fall risk and no interventions were initiated. Resident #7's fall score on readmission on 3/27/23 was seven, still low fall risk. The DON acknowledged the baseline care plan dated 3/2/23 safety section did not indicate any fall interventions set in place. The baseline care plan had one and two person assistance for transfers selected. The DON said the staff error on the side of more assistance so a two person assistance was preferred for most residents. CNA #1 was interviewed on 5/9/23 at 2:28 p.m. He said he checked the white board in the resident's room to see if the resident was a one or two person transfer. He said the physical therapist would let the staff know if needed whether the resident was a one person or two person transfer. He said he always wore a gait belt as part of his uniform and always used a gait belt to transfer. He said he would stand behind a resident when transferring, depending on the resident's transfer status. He said some residents required both staff members for transfers and may need to stand beside the resident. He said if he needed a second staff member to do a two person transfer he would call them on the headset. CNA #2 was interviewed on 5/9/23 at 2:51 p.m. He had worked at the facility for two years and on the evening shift. He said he learned about how to transfer a resident by the daily resident sheet, talking with the CNAs at shift change and talking with the resident. There was a white board in the resident's room and under transfers it listed how many people to use and the equipment to use. He said he did use a gait belt to help prevent falls. He said each resident that was a fall risk wore a wristband. He said using a gait belt assisting the resident, he stood in front of the resident to help get them out of a chair and then he would stand to the side as he assisted them to walk. The wall mounted computerized clinical kiosk was observed and there was no place to review the resident's transfer status. CNA #3 was interviewed on 5/9/23 at 3:13 p.m. She said she did not receive training on how to complete a resident transfer nor did she receive any kind of inservice. She was not sure if it (not receiving the training) was because she had been a CNA for so long. The DON was interviewed on 5/9/23 at 3:25 p.m. She said the facility did not complete a facility wide transfer education for nursing staff after Resident #7's fall with an injury. The physical therapist assistant (PTA) was interviewed on 5/9/23 at 3:26 pm. She said a resident who was maximum assistance was considered a two person assist with transferring. Once a transfer status was verified by PT it was written on the communication boards in the resident's room and verbally told to the resident's nurse at time of determination.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Ensure the surface disinfectant time was followed for proper disinfection; -Ensure resident rooms were cleaned and disinfected properly; and, -Ensure staff performed proper hand hygiene. Findings include: I. Professional reference According to the Center for Disease Control (CDC), Hand Hygiene Basics retrieved on 5/15/23 from: http://www.cdc.gov/handhygiene/basics.html (2019) read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings). II. Facility policy and procedures The Disinfection Room Cleaning and Pest Control policy, revised 8/6/2020, was received from the nursing home administrator (NHA) on 5/9/23 at 11:52 a.m. revealed in pertinent part, procedures to provide guidelines for cleaning and disinfection the environment in order to minimize the spread of healthcare-associated infection due to environmental contamination. An EPA (Environmental Protection Agency) registered hospital grade disinfectant must be used according to the manufacturer's specification. Place contaminated waste promptly into designated containers. According to the Midlab HP202 product label, undated, received from the NHA on 5/9/23 at 11:52 a.m. revealed in pertinent part, virucidal activity SARS-related coronavirus 2 (virus caused COVID-19), influenza virus type A, the cleaner requires one minute dwell (surface disinfectant) time. Hepatitis B has a five minute dwell time. Methicillin resistant staphylococcus aureus (MRSA) has a ten minute dwell time. The Handwashing policy and procedure, revised 9/28/22, received from the NHA on 5/9/23 at 11:52 a.m. revealed in pertinent part, hand washing before and after contact with any patient is the most important measure that can be taken to prevent the spread of infection. Hand washing will occur at the following times; before applying and after removing gloves, before passing medications or giving injections. After contact with any equipment or environmental surface that might have been soiled or contaminated. Adjust water to a comfortable level, wash hands vigorously scrubbing with soap for a minimum of 20 seconds. III. Observations and staff interviews Housekeeper (HSK) #1 was observed on 5/8/23 at 9:19 a.m. cleaning room [ROOM NUMBER]. She applied gloves, collected disinfectant spray and sprayed the main door inside and out, resident wheel chair, cushion, chairs, television stand, resident reaching tool and recliner. At 9:21 a.m. she wiped items down in the above order using one cloth for all areas. At 9:23 a.m. she sprayed the bedside table, bedroom sink/vanity counter top, bathroom door inside and out. She retrieved a new cloth and wiped down the bedside table, inside the sink bowl then the handles on the faucet then inside sink bowl again, vanity counter top, paper towel dispenser opened and assessed for paper towels. HSK #1 wiped down the bathroom door inside and out with the same towel. She continued cleaning the bathroom, starting with the sink in the bathroom by spraying disinfectant and wiping it down immediately, not waiting for the one minute surface disinfectant time and wiped with the same cloth as above. She obtained the toilet bowl cleaner from the cart and applied it to the toilet bowl, scrubbed bowl immediately. She removed gloves, obtained the broom and swept up large items on the floor in the room. She applied new gloves, without hand hygiene being performed. She wiped down the bedside commode laying on the floor in the bathroom. She used the same cloth to wipe the outside toilet and lid from top to bottom. She removed her gloves and sanitized her hands with an alcohol based hand rub (ABHR). Sprayed the bathroom floor with disinfectant from the bottle along with a mop pad and allowed it to sit for two minutes while she collected trash from the room. She moped the floor and shower floor with the same mop head, but the shower was never sprayed down prior. She replaced the mop with the dirty mop pad on the cart without removing the mop pad and placing it into a dirty bag. She applied gloves and entered the bathroom and picked up on old wound dressing from the shower. HSK #1 stated she would return to vacuum the room later. -HSK #1 failed to disinfect the call light, bed control and television remote that were high touch items. HSK #1 was interviewed on 5/8/23 at 9:35 a.m. She said the facility used HP202 disinfectant spray for all cleaning and it had a surface disinfectant time of one minute. She said once the surface was sprayed with the disinfectant, staff had to wait one minute before wiping it so it could properly disinfect. Staff were to change gloves between resident rooms, and hand hygiene occurred if hands appeared to be soiled. She acknowledged she used the same towel on multiple areas and probably should have used more towels in the room. HSK #1 said staff should work from the cleanest to the dirtiest areas. High touch areas in resident rooms were door handles, their bedside tables, call light and bed controls. She acknowledged she failed to spray the shower down and clean it prior to mopping the shower floor and some high touch areas like the television remote, call light and bed control. HSK# 2 was observed on 5/8/23 at 9:48 a.m. cleaning room [ROOM NUMBER] She performed hand hygiene with ABHR and applied gloves. She collected disinfectant spray and two towels. She sprayed all the doors, walker, sink and soap dispenser. She failed to wait one minute and started wiping the sink after 33 seconds. She used a new rag for the door to the bathroom. She changed her gloves and did not perform hand hygiene. She continued in the bathroom spraying down toilet top to bottom on the outside. She cleaned the sink with cloth inside the bowl then the handles to the faucet. She then wet a paper towel and wiped the mirror. She collected the toilet bowl brush and cleaner from the cleaning cart. She applied cleaner to the bowl and scrubbed the toilet bowl by brushing hard causing water to splash onto the wall. She returned the toilet bowl brush and cleaner to the cart. She then wiped down the toilet top to bottom on the outside with new cloth. She then touched the toilet paper roll with dirty gloves to make a triangle. HSK #2 then collected the mop pad and the mop. The mop had a disinfectant reservoir for floor cleaner, she mopped the bathroom floor, removed the mop pad and placed it into a dirty bag on the cart. She removed her gloves. She failed to clean the shower in the bathroom. -HSK #2 failed to allow time for chemicals to disinfect, change gloves after cleaning a soiled area, to clean from cleanest to dirtiest, disinfect high touch areas and perform hand hygiene at appropriate levels. HSK #2 was interviewed on 5/8/23 at 10:04 a.m. She said the disinfectant the facility used was HP 202 and it had a one minute surface disinfectant time to disinfect and kill all the germs. She said changing gloves occurred when gloves appeared soiled. Staff could use soap and water or ABHR for hand hygiene. HSK #2 said high touch areas in a residents room were the call light, phone, bed control, television remote and bedside tables. She acknowledged she did not clean some high touch areas, the shower and she touched the toilet paper with dirty gloves after cleaning the toilet. The NHA, who was the housekeeper director, was interviewed on 5/9/23 at 11:50 a.m. The NHA said housekeeping employees trained with his lead housekeeper for a week prior to going independent on the floor. They covered infection control topics like isolation rooms for droplet, contact and airborne. Personal protective equipment donning and doffing, gloves, gown, face shield/goggles and mask. Cleaning rooms should be cleaned from the cleanest areas to the dirtiest. In training, staff were educated to ensure the surface disinfectant time was followed to disinfect appropriately. The facility used HP202 as its disinfectant and had a one minute surface disinfectant time for COVID-19. He acknowledged the chemical HP 202 required higher surface disinfectant time to effectively combat other organisms. HP202 chemical was a concentrate, the facility had a dispenser that mixed it for staff so it was at the correct concentration to be effective. The NHA said staff should change their gloves after completing a dirty task in housekeeping prior to going to a cleaner area and between rooms. He acknowledged staff should not be cleaning the sink bowl then faucet or counters as the sink bowl was considered the dirtiest part out of these areas. He acknowledged HSK#2 should not have touched the toilet paper dispensed with soiled gloves she had used to scrub the toilet bowl, nor should HSK #2 use the toilet brush on the bowl to cause splashing. He said towels used to wipe down should be changed when cleaning, a new area of the towel for each surface and then changed out. If the facility had a resident who had an infection, staff were educated on longer surface disinfectant times for the HP 202 chemical to be effective along with staff understanding that they were to clean isolation rooms last to help prevent spread of infection. He said these types of situations were communicated verbally and no written education was given to the staff to communicate increased surface disinfectant times. Licensed practical nurse (LPN) #1 was observed on 5/8/23 at 12:05 p.m. passing medications. LPN #1 entered a resident room to perform a blood glucose check. Upon entering the room, she washed her hands by turning on the water, wetting her hands, applying soap and rubbing her hands together for ten seconds then rinsing her hands for four seconds. She grabbed a paper towel, dried her hands, collected a second towel and turned off the water. She then applied gloves and performed a glucose check. -LPN #1 did not meet the minimum 20 seconds when washing her hands. LPN #1 returned to the cart, charted blood glucose level and collected medication for the same resident. Upon return to residents room, LPN #1 washed her hands with soap and water by turning on water, wetting her hands, applied soap, rubbed her hands together for ten seconds, rinsed the soap off in five seconds and obtained a paper towel to dry her hands and a second towel to turn off water. -LPN #1 did not meet the minimum 20 seconds when washing her hands. LPN #1 was interviewed on 5/8/23 at 4:26 p.m. She said hand hygiene performed by staff was completed by turning on water, wetting hands, applying soap, washing/rubbing hands together for 20 to 30 seconds then rinsing with water, drying with paper towel and turning off faucet with paper towel. She said she did not shake her hands. During medication administration, staff could use ABHR between residents unless administering a shot or checking blood glucose levels then she needed to wash with soap and water. LPN #1 acknowledged she should have washed her hands longer after administration of insulin and glucose checks. The director of nursing was interviewed on 5/9/23 at 11:19 a.m. She said hand hygiene should be performed between residents and when hands were visibly soiled. Staff could use ABHR or soap and water to complete hand hygiene. If soap and water was used, it was a minimum 20 seconds of rubbing hands together with soap and water or singing the alphabet song. Staff were annually assessed for hand hygiene and were educated regularly on infection control. If a specific infection control issue was observed staff were educated for compliance.

Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for one (#32) of three residents reviewed for respiratory care out of 24 sample residents. Specifically, the facility failed to for Resident #32: -Ensure oxygen tubing was marked with the date and initial when replaced per physician orders; -Ensure oxygen humidifier bottle was marked with date and initial when replaced for Resident #32 per physician orders; -Ensure oxygen humidifier bottle was not empty of sterile water to prevent nasal dryness and per physician orders; -Ensure there were complete oxygen orders to include the amount of oxygen to be administered; and, -Ensure there was a comprehensive oxygen care plan. Findings include: I. Facility policy and procedures The Oxygen Administration policy and procedure, revised 2/23/21, was provided by the nursing home administrator (NHA) on 1/26/22 at 12:22 p.m. It read in pertinent part, .Verify that there is a physician's order for administering oxygen. The physician's order must include liter flow with parameters, frequency, and duration of oxygen treatment. If the order if unclear or incomplete, clarify the order with the physician .Review the patient's care plan to identify any special needs of the patient .Turn on the oxygen, adjust the flow as prescribed by the physician .For wall connections, check that there is water in the humidifying jar and that the water level appropriate. II. Resident #32 A. Resident status Resident #32, age 83, was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/2/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required extensive assistance with two persons for toileting, transfers, and dressing. Partial/moderate assistance with bed mobility. Oxygen therapy was documented on the MDS assessment. B. Observation and interview On 1/24/22 at 1:06 p.m. Resident #32 was observed in bed. She was wearing an oxygen nasal cannula. The oxygen was set at 3 liters per minute (LPM). The oxygen humidifier bottle was empty of water and was not dated when it was last changed. The oxygen tubing was not labeled with the date when it was last changed. Resident #32 said she did not remember the staff changing her oxygen tubing. On 1/25/22 at 2:13 p.m. Resident #32 was laying down and getting ready to take a nap. She was wearing an oxygen nasal cannula and the oxygen was set at 2.5 LPM. The oxygen humidifier bottle was empty of water and was not dated when it was last changed. The oxygen tubing was not labeled with the date when it was last changed. On 1/26/22 at 9:55 a.m. Resident #32 was seated bedside in a wheelchair. She was wearing an oxygen nasal cannula and the oxygen was set at 2.5 LPM. The oxygen humidifier bottle was empty of water and was not dated when it was last changed. The oxygen tubing was not labeled with the date when it was last changed. Two extra oxygen tubings were in the room, both unlabeled and not dated, one hanging by door on a hook, not in a bag, and one laying on the table (green in color) it appeared dirty with light brown/yellow areas, and was not in a bag. C. Record review The January 2022 computerized physician orders revealed orders for oxygen per nasal cannula (NC) to maintain oxygen saturation (SpO2) greater than 90%. Document liters per minute (LPM) quantity sufficient (QS). May titrate/discontinue oxygen (O2) LPM as tolerated while maintaining SpO2 greater than 90%. -However the physician's order did not include a baseline liter flow amount of oxygen, or frequency (i.e. continuous or intermittent). The computerized physician orders revealed orders to change oxygen humidifier bottle each week on Saturday evening (p.m.) shift. Special instructions were to initial and date bottle when replaced once a day on Saturday. -However, the humidifier bottle was empty of water during three days of observation (1/24/22, 1/25/22, and 1/26/22). In addition, the humidifier bottle did not have any initial or date on the bottle during the three days of observations. It was brought to the attention of the director of nursing (DON) on 1/26/22. The medication administration/treatment administration record (MAR/TAR) revealed registered nurse (RN) #2 signed and dated the MAR/TAR on 1/22/22 as replacing the oxygen humidifier bottle and had the initial and dated bottle when replaced. -However there was no initial or date on the bottle as witnessed by the DON on 1/26/22. The January 2022 computerized physician orders revealed to change the oxygen tubing each week on Saturday p.m. shift. Special instructions were to initial and date both long and short tubing when replaced once a day on Saturday. -However, the oxygen tubing was not dated or initial during the three days of observation (1/24/22, 1/25/22, and 1/26/22). It was brought to the attention of the director of nursing (DON) on 1/26/22. The medication administration/treatment administration record (MAR/TAR) revealed RN #2 signed and dated the MAR/TAR on 1/22/22 as changing the oxygen tubing and had initial and dated both long and short tubing when replaced. -However there was no initial or date on the oxygen tubing as witnessed by the DON on 1/26/22. The comprehensive care plan, last updated 1/10/22, identified problem that the resident was at risk for respiratory distress, and complications related to patchy interstitial opacities (scarring of lung tissue), acute hypoxemic respiratory failure (absence of enough oxygen in the tissue to sustain bodily functions), related to [CONDITION(S)] (airflow blockage and breathing-related problems) and required head of bed to be elevated to prevent shortness of breath; O2 dependence; incentive spirometer per physician orders. The goal was listed as resident airway will remain patent with adequate gas exchange throughout the the next review and will be free from signs and symptoms of respiratory distress e.g. rapid shallow breathing, blue lips or fingernails, pursed lips, increased anxiety, complaint of shortness of breath through the next review. Approach included to administer medication per physician order. -However, the care plan was incomplete and did not include the safe handling, humidification, cleaning, storage, and dispensing of oxygen, including proper infection control practices. The facility failed to identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: The type of oxygen delivery system; when to administer, such as continuous or intermittent and/or when to discontinue; equipment settings for the prescribed flow rates; monitoring of SpO2 levels and/or vital signs, as ordered; and based upon the individual resident's risks, if applicable, monitoring for complications, such as skin integrity issues related to the use of a nasal cannula. D. Staff interview RN #1 was interviewed on 1/26/22 at 9:59 a.m. She said she would know what to set oxygen level amounts LPM based on info she got from the hospital and also depending on keeping oxygen above 90% for Resident #32. RN #1 said they have standing orders to place a resident on oxygen. RN #1 said there was not an actual specific LPM order, yet some residents do have specific parameters. RN #1 said the hydration oxygen bottles should be initial and dated when they were last replaced and also the oxygen tubing should be initial and dated when they were last replaced. RN #1 said when the oxygen humidification water runs out they are supposed to be changed and replaced right away. RN #1 viewed Resident #32's hydration oxygen bottle and oxygen tubing and acknowledged that neither were initial or dated and that the humidifier bottle was empty. RN #1 said the risk of not having water in humidifier bottles was nose dryness and the risk of not having clean, dated, oxygen tubing was infection. The DON was interviewed on 1/26/22 at 10:30 a.m. The DON said that the oxygen humidifier bottles and oxygen tubing should be dated and initial. The DON viewed Resident #32 hydration oxygen bottle and oxygen tubing and acknowledged that neither was initial or dated. RN #32 said the facility had run out of the humidifier oxygen bottles and it was placed on order last Friday (1/21/22) . The DON said the risk of not having the oxygen hydration was nasal dryness. The DON said the risk of not having clean, dated, oxygen tubing was infection. The DON said they have no specific dosage for oxygen LPM because most residents are titrating. The DON viewed the three oxygen tubing in Resident #32 room and acknowledged none had dates or labels. The DON said one was from the hospital because it was a green tubing (and the facility does not carry that type) and it should be thrown away, and said it looked dirty. The DON said all the tubing will be replaced and labeled. The DON said the humidifier bottles should be changed weekly and when empty. The DON was interviewed on 1/27/22 at 9:05 a.m. The DON said she has been in DON position for two months but she was familiar with the facility policies and procedures related to oxygen. The DON said she was slowly educating the nursing staff on the policies. She said the quality assurance (QA) and transportation staff are responsible to order the humidifier water bottles on a regular basis and if extras are needed. The DON said the new humidifier bottles came in yesterday 1/26/22 ( the DON provided documentation of the last humidifier order which was placed Friday 1/21/22 at 7:31 pm). The DON provided oxygen education documentation, dated 1/26/21, of nursing staff. Identified concerns (after brought to the DON's attention); Not dating oxygen tubing, not changing humidifying bottles when empty, not keeping oxygen tubing in bag. Possible negative outcomes: Infection control. 13 staff members were educated. The DON said staff members had gone through the facility and changed and updated all humidifier bottles and oxygen tubing and bags, and labeled and dated yesterday, 1/26/22. The DON was interviewed on 1/27/22 at 11:23 a.m. She acknowledged that RN #2 had documented on the MAR/TAR that the oxygen tubing and humidifier bottle was changed and that it had been initial and dated. The DON said RN #2 did not initial or date the humidifier bottle or oxygen tubing although he documented that he had. The DON also acknowledged that RN #2 was not one of the 13 staff members who were recently educated on this subject on 1/26/22. She said RN #2 worked tonight on 1/27/22, and he would be educated. The NHA was interviewed on 1/27/22 at 12:02 p.m. He said he expects the staff to follow the facility policy and procedures related to oxygen. III. Facility follow-up The NHA provided documentation on 1/28/22 at 9:41 a.m. The education documentation, dated 1/26/22, revealed RN #2 completed oxygen training concerning not dating oxygen tubing, not changing the humidifier bottle when empty, not keeping oxygen tubing in a bag. -However the education of RN #2 did not occur until 1/27/22 according to the DON, see interview above.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents received adequate supervision to prevent accidents out of three sample residents reviewed. Specifically, the facility failed to ensure an assessment of Resident #1 was completed by a registered nurse (RN) following a fall. Findings include: I. Professional references According to the Colorado Department of Regulatory Agencies website, Board of Nursing: Laws, Rules and Policies https://dpo.colorado.gov/Nursing/Laws (retrieved 8/27/2020), The practical nursing student is taught to identify normal from abnormal in each of the body systems and to identify changes in the patient's condition, which are then reported to the RN or MD (medical doctor) for further or full assessment. II. Resident #1 A. Resident status Resident #1, age 95, was admitted on [DATE]. According to the September 2019 computerized physician orders [REDACTED]. The 9/16/19 minimum data set (MDS) assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding daily tasks of life. She required extensive assistance of two people with bed mobility, transfers and toileting. She required extensive assistance of one person with personal hygiene, eating and dressing. She was totally dependent with one person assistance for bathing. She was not steady and only able to stabilize with staff assistance for moving from a seated to a standing position. B. Record review The 9/18/19 nursing progress note revealed Resident #1 was being assisted by a certified nurse aide (CNA) in the shower room. While the resident was seated in the shower chair, the CNA dried off her legs. The resident leaned forward, fell on to the CNAs back and then onto the floor. The resident sustained [REDACTED]. It indicated the resident was assisted from the floor by the licensed practical nurse (LPN) and the CNA following an assessment of the resident. It did not indicate an RN was notified to complete an assessment of the resident immediately following the fall and prior to moving the resident off the floor. The 9/18/19 fall investigation revealed the resident fell forward, while sitting in a shower chair, onto a CNA and then onto the ground, while in the shower room. The resident sustained [REDACTED]. The physician and resident representative were notified at 10:30 a.m. A treatment was put into place to address the skin tear to the resident's left wrist. The fall investigation was completed by an LPN. It did not indicate an RN had conducted an assessment of the resident following the fall. C. Staff interviews RN#1 was interviewed on 8/25/2020 at 4:43 p.m. She said following a fall sustained by a resident, an RN should complete a head to toe assessment of the resident to determine if the resident sustained [REDACTED]. She said a LPN cannot perform an assessment because it is not within their scope of practice. She said an LPN could gather and report information but not assess a resident for injury. The director of nursing (DON) was interviewed on 8/25/2020 at 4:35 p.m. She said following a fall, an RN should complete a head to toe assessment of the resident to determine if the resident sustained [REDACTED]. She said she was unable to find documentation to indicate an RN assessment of the resident was completed the fall sustained by the resident on 9/18/19. She said the documentation indicated an LPN completed the assessment of the resident. She said the physician's assistant (PA) had come into the facility and assessed the resident following the fall. She confirmed the resident had fallen at 6:00 a.m. on 9/18/19 and the PA note indicated 10:59 a.m. She said she could not confirm what time the PA assessed the resident. She confirmed the evaluation of the resident was not immediately following the fall and after the resident had been moved from the ground and was back in her room.

Based on observations, record review and interviews, the facility failed to follow an effective infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19 in three of three neighborhoods. Specifically, the facility failed to: - Ensure visitors and staff were actively screened for the signs and symptoms of COVID-19; - Ensure residents were encouraged to use source control precautions during care requiring direct contact with staff; and, - Ensure staff engaged in accepted hand hygiene practices at the appropriate time. Findings include: I. Screening A. Professional standards According to The Centers for Disease Control and Prevention (CDC), Preparing for COVID-19 in nursing homes, last updated 6/25/2020, Screen all HCP at the beginning of their shift for fever and symptoms of CO VID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 symptoms. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Screen visitors for fever (T=100.0°F), symptoms consistent with COVID-19, or known exposure to someone with COVID-19. Restrict anyone with fever, symptoms, or known exposure from entering the facility. Ask visitors to inform the facility if they develop fever or symptoms consistent with COVID-19 within 14 days of visiting the facility. Retrieved 7/20/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. B. Facility policies and procedures The infection prevention and control policy and procedures dated 3/1/2020, was provided by the nursing home administrator (NHA) on 7/15/2020 at 10:20 a.m. It read in pertinent part: The facility will implement practices to reduce the spread of COVID-19 following CDC, CMS (Centers for Medicare and Medicaid Services), state and local health department guidance. Any patient with confirmed coronavirus will be discharge to the hospital secondary to CDC guidelines for negative pressure room. Employee and visitor screening: The facility will actively screen and restrict employees and visitors from entering the facility for those who meet the following criteria: signs and symptoms of a respiratory infection, such as fever, cough, and shortness of breath or sore throat. Has the individual in the last 14 days had contact with someone with a confirmed [DIAGNOSES REDACTED].? Has the individual, in the last 14 days travelled internationally to countries with sustained community transmission? Resides in the community where community-based spread COVID-19 is occurring. C. Observations 7/15/2020 Surveyors entered the building at 9:05 a.m. and were escorted to the front desk to be screened. The screening area included a hand sanitizer pump, a thermometer, alcohol wipes and the screening log. Signage placed at the desk listed potential signs and symptoms of COVID-19 such as cough, shortness of breath (SOB), sore throat, chills and fever. The screening form included in the log listed date, name, telephone number, location and noted whether the person passed the screen. The business office manager (BOM), who was also the screener at the time of the visit, measured the surveyors temperatures and asked them to complete the screening form. The BOM did not screen or ask the surveyors about signs and symptoms, travel or potential exposure to COVID-19. The BOM did not encourage hand hygiene and the surveyors were allowed to proceed into the facility. 7/16/2020 At 10:35 a.m. a vendor was observed at the front entrance He wore a pair of disposable gloves and a mask. The receptionist greeted the vendor as he entered the facility, remarking she had not seen him for awhile. The receptionist measured the vendor's temperature and she asked him to fill out the screening form. The receptionist did not screen or ask the vendor about signs and symptoms, travel or potential exposure to COVID-19. She did not encourage hand hygiene and the vendor proceeded into the facility wearing the same disposable gloves. Surveyors entered the building behind the vendor and were screened in the same manner. At 2:00 p.m., the employee screening process was observed. Staff entered the building and went directly to a nearby nurses' station. A computer for staff to enter time in/out was positioned on the counter of the nurses' station. Signage that listed signs and symptoms of COVID-19 was placed next to the time clock. A thermometer and screening log were available at the nurses' station for staff to measure their own temperatures and fill in the screening form. There was not a designated staff at the nurses' station to actively screen staff as they entered the facility and proceeded to their work area. D. Staff interviews The BOM was interviewed 7/15/20 at 11:15 a.m. The BOM said he was filled in for the receptionist who was off that day. The BOM said he was responsible to screen visitors at the front desk area and staff were responsible to screen themselves at the nurses' station. He said staff took their own temperature and another staff would verify the temperature. He said the process to screen visitors was to take their temperature and ask them if they had any signs and symptoms or had been exposed to anyone with COVID-19. He said if the visitor answered yes to any of the COVID-19 symptoms questions, the visitor would not be allowed in the facility and he would notify the nurse. THe BOM said when he took the surveyor's temperatures, he should have screened for the signs symptoms for COVID-19 but he forgot to do so. The receptionist was interviewed on 7/16/20 at 2:28 p.m. She said she was responsible to screen visitors. The receptionist said staff screened themselves and took their own temperature and another staff would verify the temperature. She said the screening process for visitors was to take their temperatures and screen for the signs and symptoms of COVID-19. She said if the visitor answered yes to any of the questions, she would notify the nurse and the visitor would not be allowed into the facility. She acknowledged she did not appropriately screen the vendor and the surveyors for the signs and symptoms of COVID-19. She said she should have screened for the signs and symptoms of COVID-19 to prevent potential transmission of COVID-19 in the building The NHA was interviewed on 7/16/2020 at 12:00 p.m. He said the receptionist was responsible to screen visitors and the staff screened themselves by taking their own temperature and reading the signs and symptoms signage for COVID-19 before they clock in. The NHA said the temperature measurement would be verified by another staff member but there was no one assigned specifically to actively screen staff. The NHA said the screener should actively screen visitors for the signs and symptoms of COVID-19 and should document the absence of the symptoms. The NHA said the screener should have actively screened the vendor and the surveyors for the signs and symptoms of COVID-19 to prevent the development and transmission of COVID-19. He said education would be provided to the screener. The director of nursing (DON) was interviewed on 7/16/2020 at 12:18 p.m. She said the receptionist was responsible to screen visitors. The DON said the receptionist should actively screen visitors for the signs and symptoms of COVID-19 and document the absence of COVID-19. The DON said she should have actively screened the vendor and the surveyors for the signs and symptoms of COVID-19 before allowing them into the facility. The DON said she allowed staff to take their own temperature and have another nurse or certified nurse aide (CNA) verify the temperature. The DON said the signs and symptoms for COVID-19 were listed by the time clock. She said staff were instructed to read the signs and symptoms of COVID-19 before they clock in. She said clocking in indicated the staff was not experiencing any signs and symptoms of COVID-19. The DON said the staff were trained to self-screen but was unable to provide documentation of staff training. She said she trusted her staff and stated that she hoped they would be honest and not put residents and other staff at risk for COVID-19. CNA #1 was interviewed on 7/16/20 at 2:30 p.m. She said staff entered the facility through the back entrance through the break room and then proceeded to the nurse station (without passing through a resident care area). She said there was a time clock at the nurse station where staff clock in. The CNA said she took her own temperature and another staff member would verify the temperature. She said there was a sign next to the time clock which listed signs and symptoms of COVID-19 for staff to read before they clock in. She said there was no one actively screening staff. II. Source control A. Professional standard According to CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last revised July 15, 2020, Retrieved 7/22/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Source control refers to use of cloth face coverings or face masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19 .Patients may remove their cloth face covering when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room. B. Observations 7/15/2020 At 10:01 a.m., housekeeper (HK) #1 prepared to clean room [ROOM NUMBER]. The occupant of the room, Resident #4, was newly admitted to the facility and under isolation precautions according to the clinical record. The HK gathered and donned personal protective equipment (PPE) from the cart at the entrance to the room and began cleaning. The HK did not encourage the resident to use a method of source control as she completed tasks within a few feet of the resident for several minutes. The resident did not have on a mask or use another method of source control as he spoke directly to the HK during this time. An unidentified rehabilitation therapist donned PPE and entered room [ROOM NUMBER] at 10:20 a.m. The therapist did not encourage Resident #4 to use a method of source control as he worked with Resident #4, using therabands within approximately two feet of the resident.The resident did not have on a mask or use another method of source control as he spoke directly to the therapist during this time. Two unidentified staff were observed at 10:30 a.m. as they helped the resident in room [ROOM NUMBER] stand from his wheelchair. The resident was not encouraged to use a method of source control as the two staff stood directly at his sides during the transfer. The resident, who was not wearing a mask or other method of source control, spoke directly into the faces of the staff who were assisting him. The resident was also under isolation precautions based on the signage and PPE cart at the entrance to the room. At 12:37 p.m., CNA #2 donned PPE (see additional information next section) and entered room [ROOM NUMBER] with a meal tray. The occupant of the room, Resident #5 was newly admitted to the facility and under isolation precautions according to the clinical record. CNA#2 approached the resident as he relined on the bed but did not encourage the resident to use a method of source control. The CNA stood directly next to the resident and spoke with him as she determined he needed additional assistance. The resident, who was not wearing a mask or other method of source containment, vocalized his distress to the CNA during this time. 7/16/2020 Between 12:00 p.m. and 12:31 p.m., CNA #3 was observed as she distributed room trays in hall #2. The CNA entered multiple rooms without encouraging the resident to use a method of source control. None of the residents wore a mask or used a method of source control when the CNA stood directly next to them as she helped set up their lunch tray. C. Resident interviews Resident #7 was interviewed on 7/16/2020 at 12:05 p.m. He said staff reminded him to wear a mask when he was in the hallway but never prompted him to use a method of source control when receiving care in his room, going back to his admitted . Resident #6 was interviewed on 7/16/2020 at 12:58 p.m. She said staff never reminded her to wear a mask or use another method of source control when receiving care in her room. She said she understood the potential for transmitting [MEDICAL CONDITION] but probably would not use one anyway because she felt like she could not breathe. She said she did not think this preference was a part of her care plan and did not know what she would do otherwise. D. Record review Baseline care plans and comprehensive care plans for Residents #4, #5, #6, and #7 revealed each resident was educated on COVID-19 and was expected to wear cloth face coverings or masks whenever leaving their rooms. Care plans did not include approaches to prompt residents to use source control to prevent potential transmission during in-room care. The review of care plans and nurses' notes also failed to document whether residents were cooperative with non-directed requests to use source control. Care plans did not include alternate approaches to implement preventative measures in the event a resident did not comply with such requests. E. Staff interviews CNA #3 was interviewed on 7/16/2020 at 12:31 p.m. The CNA said she knew she was supposed to make sure residents had a mask on when they were in the hall. She said she thought residents had masks with them in their rooms but she did not know she should encourage them to put them on when she entered the room to provide care. The CNA said she understood how not encouraging source control could potentially spread [MEDICAL CONDITION] from a resident to staff. Licensed practical nurse (LPN) #1 was interviewed on 7/16/2020 at 1:05 p.m. The LPN said staff were supposed to encourage residents to wear a mask if they were outside of their room but did not need to use a method of source control in their rooms if they were asymptomatic. The LPN acknowledged the potential for spreading [MEDICAL CONDITION] from newly admitted residents to staff when their COVID-19 status was unknown. She agreed new residents could be asymptomatic but still have [MEDICAL CONDITION]. The NHA and DON were interviewed on 7/16/2020 at 2:20 p.m. The NHA said all residents were expected to wear masks when going to appointments or being outside of their rooms. The DON said staff should encourage residents to use a method of source control when receiving care in their rooms. She said residents who cannot or will not wear a mask during care should be given options to try to limit the risk of transmission. The NHA said the COVID-status of newly admitted residents was unknown and that was why all new admissions undergo a 14 day quarantine. The DON and NHA agreed it was possible for a newly admitted resident to be positive for [MEDICAL CONDITION] and not have symptoms. They also agreed staff should help residents take every precaution to keep everyone at the facility safe. III. Hand hygiene A. Professional standards According to the CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last revised July 15. 2020, Retrieved 7/22/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS. According to the CDC, Retrieved 7/22/2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), HCP should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. According to the Colorado Food Establishment Rules and Regulations, effective January 1, 2019, pp. 47-48, Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and .Before donning gloves to initiate a task that involves working with food . B. Observations 7/15/2020 HK #1 was observed at 10:01 a.m. as she prepared to enter room [ROOM NUMBER]. The HK donned PPE and placed gloves on her hands. She did not perform hand hygiene prior to donning the gloves. She cleaned the room, discarded her gloves and gown and washed her hands in the bathroom. The HK adjusted her mask with her hands and, without performing hand hygiene or donning gloves, touched the handle of the door to room [ROOM NUMBER] and opened it. The resident was receiving care so the HK closed the door and moved her cart across the hallway to room [ROOM NUMBER]. The HK donned gloves without performing hand hygiene, potentially contaminating the outer surface of the gloves, and began cleaning the room. She used her gloved hands to move a carafe of water on the over-the-bed table so she could clean the table surface under the container. She continued to contact items in the room with her gloved hands including the call light button and bathroom door knob as she cleaned the room. At 10:20 a.m., an unidentified rehabilitation therapist donned PPE before entering room [ROOM NUMBER]. He did not perform hand hygiene prior to placing gloves on his hands. The therapist used his gloved hands to manipulate a set of therabands which he handed to the resident in the room. At 10:22 a.m. an unidentified nurse donned PPE before entering room [ROOM NUMBER]. She used her ungloved hands to adjust her mask twice before placing gloves on her hands. The nurse did not perform hand hygiene before touching the clean outer surface of the gloves. Between 11:30 a.m. and 11:38 a.m., the dietary manager (DM) entered the kitchen and food service area three times without washing her hands. She used her hands to open doors to the walk in freezer and refrigerator. At 11:35 a.m., the DM donned gloves without performing hand hygiene and covered an open bag of bowl lids with plastic wrap. Prior to donning the gloves, the DM held the clean outer surface of the gloves in her hands. At 11:41 a.m., the cook left the kitchen and returned several minutes later. He did not perform hand hygiene before donning gloves and separating dinner rolls for service. Prior to donning the gloves, the cook held the clean outer surface of the gloves in his hands. At 11:46 a.m., the cook donned another set of gloves before slicing orange garnishes for the meal. He did not perform hand hygiene and held the clean outer surface of the gloves in his hand prior to placing them on his hands. At 12:37 p.m., CNA #2 did not place gloves on her hands as she donned PPE to enter room [ROOM NUMBER]. The CNA delivered a meal tray and approached the resident as he reclined on his bed. Several minutes later, the CNA returned to the doorway and donned a pair of gloves without first performing hand hygiene. The CNA returned to the resident to address a care request. 7/16/2020 CNA #3 was observed between 12:00 p.m. and 12:31 p.m. as she delivered room trays to residents on hall #2. -At 12:25 p.m., CNA #3 donned PPE before entering room [ROOM NUMBER], a room under isolation. She did not perform hand hygiene prior to donning her gloves. Prior to exiting the room, CNA #3 discarded her mask, gloves and gown and wiped down the goggles she wore. The CNA did not perform hand hygiene after doffing the gloves or between resident rooms. -CNA #3 retrieved another room tray from the food cart and prepared to enter room [ROOM NUMBER]. The occupant of the room, Resident #3 was under isolation precautions for having a dry cough and a headache the day before. CNA #3 signed the book outside of the room and donned PPE. She did not perform hand hygiene prior to placing the gloves on her hands. C. Staff interviews CNA #3 was interviewed on 7/16/2020 at 12:33 p.m. The CNA said she worked at the facility for just a few weeks. She said she received training for PPE use and hand hygiene but was really nervous during the observation. She said she should have performed hand hygiene before putting on and after taking off gloves. She agreed touching the outer surface of clean gloves with unwashed or unsanitized hands could contaminate the outer surface of the glove. The DON was interviewed on 7/16/2020 at 2:20 p.m. The DON said hand hygiene was a key part of the infection prevention and control training provided to staff. The DON said staff were expected to wash or sanitize their hands before putting on and after taking off gloves as a part of basic nursing practice. The DON said oncoming staff were thoroughly trained and had to pass competencies with return demonstration prior to working with residents. She said monitoring of the infection prevention and control practices at the facility would be expanded to also include observations of dietary practices.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Perform hand hygiene before entering and exiting residents' rooms to take their vital signs (vs) on two of three hallways; -Sanitize the blood pressure (bp) cuff, temperature probe, and pulse oximeter of the vita machine, according to manufacturer instructions on two of three hallways; and -Store portable oxygen tanks off of the floor. Findings include: I. Facility policy According to the Handwashing policy dated 3/10/14, provided by the nursing home administrator (NHA) on 9/9/19 at 2:00 p.m., it identified hand washing would occur: -Before and after caring for a resident; -Before applying and after removing gloves; and -After contact with any equipment which might be contaminated. According to the Care of Therapeutic Equipment policy dated 9/4/15, provided by the NHA on 9/9/19 at 2:00 p.m., it identified: -Reusable equipment was to be decontaminated per manufacturer instructions; and -Portable oxygen tanks were not to be stored on the floor. II. Professional reference On 9/12/19 at 2:45 p.m. the DON identified the facility utilized Lippincott as its professional reference for catheter care and hand hygiene. According to Lippincott's Nursing Center (April (YEAR)), The patient/consumer experience of partnering with health care professionals with hand hygiene compliance: a systematic review protocol, retrieved from: https://www.nursingcenter.com/journalarticle?Article_ID= 09&Journal_ID= 80&Issue_ID= 93, it identified: -Hands played a role in the incidence of infection and the spread of microorganisms, as infectious agents could be transmitted by touch. -Hand hygiene was considered to be one of the most important infection control actions to help minimize the risk of infection. -Improved hand hygiene practices were associated with sustained decrease in the incidence of infections. III. Observation An observation on 9/9/19 at 8:20 a.m. revealed the facility had three halls: #1, #2, and #3. An observation on 9/9/19 at 6:47 p.m. revealed a portable oxygen tank sat on the floor outside of room [ROOM NUMBER], in hall #2. An observation on 9/10/19 at 2:21 p.m. revealed certified nurse aide (CNA) #6 entered room [ROOM NUMBER] (hall 2) with the vita machine, CNA #6 did not perform hand hygiene, and told the resident she was going to take his vs. She used the bp cuff, pulse oximeter, and temperature probe (with cover) to take his vs. She did not wipe the bp cuff, pulse oximeter, the temperature probe and their respective cords with a Micro Kill + wipe (disinfectant wipe) before or after she took his vs. She exited his room without performing hand hygiene. An observation on 9/10/19 at 2:27 p.m. revealed CNA #6 entered room [ROOM NUMBER] (hall 2) with the vita machine and did not perform hand hygiene. She wiped the bp cuff and pulse oximeter with a Micro Kill + wipe; with her bare hands. She placed the wet bp cuff on the resident's left arm, and placed the wet pulse oximeter on the resident's left index finger. She placed the temperature probe with cover under the resident's tongue. She did not wipe the vs equipment after she took her vs, and exited the room without performing hand hygiene. An observation on 9/10/19 at 2:30 p.m. revealed CNA #6 entered room [ROOM NUMBER] (hall 2) with the vita machine and she did not perform hand hygiene. She wiped the bp cuff and pulse oximeter with a Micro Kill + wipe, with her bare hands. She placed the wet bp cuff on the resident's left arm, and placed the wet pulse oximeter on the resident's left index finger. She placed the temperature probe with cover under her tongue. She did not wipe the vs equipment after she took the resident's vs, and then she exited the room without performing hand hygiene. An observation on 9/10/19 at 2:34 p.m. revealed CNA #6 entered room [ROOM NUMBER] (hall 2) with the vita machine and did not perform hand hygiene. She wiped the bp cuff and pulse oximeter with a Micro Kill + wipe; with her bare hands. She placed the wet bp cuff on the resident's right arm, and placed the wet pulse oximeter on the resident's right index finger. She placed the temperature probe with cover under the resident's tongue. She did not wipe the vs equipment after she took his vs, and then she exited the room without performing hand hygiene. An observation on 9/10/19 at 2:37 p.m. revealed CNA #6 entered room [ROOM NUMBER] (hall 2) with the vita machine, and she did not perform hand hygiene. She did not wipe the bp cuff, pulse oximeter, temperature probe, and vs machine with a Micro Kill + wipe prior to taking the resident's vs. Then she exited the room without performing hand hygiene, and she did not wipe vs machine with a Micro Kill + wipe after using. An observation on 9/10/19 at 5:31 p.m. revealed a portable oxygen tank sat on the floor outside of room [ROOM NUMBER], in hall #3. An observation on 9/10/19 at 5:44 p.m. revealed the portable oxygen tank remained on the floor outside of room [ROOM NUMBER], in hall #3. IV. Record review According to the manufacturer's label for Medline's Micro Kill+, provided by the NHA on 9/9/19 at 2:00 p.m. it identified: two minutes of wet time was required to disinfect (kill a variety of pathogens) on items treated with the wipes, items were to be wiped thoroughly when the wipes were used for cleaning, the wipes were not to touch clothing, and hands were to be washed thoroughly after handling the wipes. V. Staff interviews CNA #1 was interviewed on 9/10/19 at 10:35 a.m. She said she said was supposed to preform hand hygiene when entering and exiting resident rooms. CNA #6 was interviewed on 9/10/19 at 5:54 p.m. She said staff were supposed to use Micro Kill + wipes to wipe the bp cuff and pulse oximeter before use on each resident. She said staff were supposed to sanitize their hands when they entered and exited resident rooms. She said she was not told by the facility to allow for a dry time when she used the disinfectant wipes to clean the bp cuff, pulse oximeter, and temperature probe between residents. CNA #2 was interviewed on 9/11/19 at 3:55 p.m. She said she received hand washing training during monthly facility meetings. She said she was supposed to use hand sanitizer before entering and exiting resident rooms. CNA #3 was interviewed on 9/11/19 at 3:45 p.m. She said she received hand washing training during monthly facility meetings. She said she was supposed to use hand sanitizer before entering and exiting resident rooms. She said staff were supposed to use the Micro Kill + wipes (she pointed to the container which sat on the vita machine) to clean the b/p cuff and the pulse oximeter. She said the facility did not tell her she had to wait after she wiped the b/p cuff and the pulse oximeter before it was used on another resident. CNA #7 was interviewed on 9/12/19 at 10:20 a.m. She said portable oxygen tanks should not be stored on the floor because doing so could cause infections to the residents. She said they were supposed to be stored on a table in the resident's room or hung in the storage room. CNA #8 was interviewed on 9/12/19 at 10:25 a.m. He said staff were not supposed to place portable oxygen tanks on the floor because that prevented residents from getting an infection. He said they were supposed to be stored on a table in the resident's room or hung in the storage room. CNA #5 was interviewed on 9/12/19 at 10:33 a.m. She said staff were not supposed to place portable oxygen tanks on the floor because that prevented residents from getting an infection. She said they were supposed to be stored on a table in the resident's room or hung in the storage room, or behind their wheelchair. VI. DON interview The DON was interviewed on 9/12/19 at 1:54 p.m. She said staff were to perform hand hygiene before entering and exiting resident rooms, and between the cares they provided; per infection control procedures. She said portable oxygen tanks were supposed to be stored in the resident's room or hung on the backs of their wheelchairs, not on the floor (outside of nor inside of resident rooms). She said the Micro Kill + required two minutes to disinfect and staff were not to place equipment (used to take vs), directly on residents when the equipment was still wet from being wiped clean with the disinfectant. The DON was interviewed a second time on 9/12/19 at 2:10 p.m. She said she planned to re-educate and re-train her staff on hand hygiene, storage of portable oxygen tanks, and infection control procedures. VIII. Professional standards The Centers for Disease Control and prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 4/29/19, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations : Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer (ABHS) immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean site on the same patient, after touching a patient or a patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, or after known or suspected exposure to spores. VIIII. Cleaning equipment [NAME] Observations On 9/9/15 at 11:15 a.m., the vitals machine on hallway three was observed without disinfecting wipes. Certified nurse aide (CNA) #11 was observed on 9/9/19 starting at 2:15 p.m. She was observed to take the vitals (blood pressure (BP), oxygen saturation, and temperature) of three residents in hall three. The following observations were made: --The BP cuff and pulse oximeter on the vitals machine were not disinfected between residents. CNA #11 was observed on 9/9/19 starting at 2:15 p.m. The following observations were made: --She wiped off the BP cuff with a quick swipe on both sides of the cuff with a disinfecting wipe after it fell on the floor, rolled it up without allowing it to dry and placed it on the vitals machine. The CNA failed to keep the BP cuff wet during the dwell time of two minutes and air dry. This was the only observation of a disinfectant wipe used on the vitals machine. --The BP cuff and pulse oximeter on the vitals machine were not disinfected between residents. B. Staff interviews CNA #11 was interviewed on 9/11/19 at 2:37 p.m. She said the vitals machine should be cleaned between each resident, wiping down the parts that came in contact with the resident. She said a standard bleach wipe was used to sanitize the equipment with a dwell time of 90 seconds to two minutes. CNA #14 was interviewed on 9/11/19 at 2:54 p.m. She said the BP cuff, thermometer, and pulse oximeter of the vitals machine were to be cleaned and hands sanitized between residents. She said the dwell time was five minutes between residents. X. Hand washing [NAME] Observations On 9/9/19 at 2:15 p.m., CNA #11 did not sanitize her hands with an alcohol-based rub (ABR) or wash her hands with soap and water after taking vitals in between residents. CNA #12 was observed on 9/10/19 starting at 2:14 p.m. She took the vitals of nine residents in hall three. The following observations were made: --She dispensed ABR, rubbed her hands together and then dried her hands on her pants and wiped off the excess ABR between just three of the nine residents.

Based on interviews and record review, the facility failed to ensure one (#17) of one out of 21 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically, the facility failed to: -Have documentation Resident #17's complaint was investigated; and, -Ensure Resident #17 was informed of the steps taken to resolve her complaint. Findings include: I. Facility policy and procedure The Grievance Policy and Procedure, dated 2/21/18, was provided by the director of nursing (DON) on 9/12/19 at 8:30 a.m. It read, in pertinent part, Patients and families are encouraged to express concerns to any member of our staff and are informed of this policy upon admission. -The Administrator (Grievance Official) will be responsible to provide feedback to the patient or family member as the grievance is investigated. -Patients may file grievances anonymously and/or verbally. -The patient/representative has the right to obtain a written decision regarding his/her grievance. -All written grievance decisions include: a. The date the grievance was received; b. A summary statement of the patient's grievance; c. The steps taken to investigate the grievance; d. A summary of the pertinent findings or conclusions regarding the patient's concerns; e. A statement as to whether the grievance was confirmed or not confirmed; f. Any corrective action taken or to be taken by the facility as a result of the grievance; and g. The date the written decision was issued. II. Resident status Resident #17, was admitted on [DATE]. According to (MONTH) 2019 computerized physician orders [REDACTED]. The 9/8/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She did not exhibit behaviors or resist care. She required extensive one-person assistance with bed mobility, transfers and toilet use. It was documented she was on a physician-prescribed weight-loss regimen. [NAME]Resident interview Resident #17 was interviewed on 9/9/19 at 6:17 p.m. She said she did not receive her [MEDICATION NAME] (medication which reduces levels bad cholesterol and increases levels of good cholesterol) the previous night. She said the nurse told her it was probably not that important. She said last week the facility ran out of blood glucose test strips and she did not have her blood glucose taken per her physician order [REDACTED]. She said she was concerned because her blood glucose had been over 200 since she had been at the facility and she did not want to have to take insulin injections. She said the facility served meals high in carbohydrates (sugar, starch, and fiber) and she had recently lost over 150 pounds and did not want to gain weight or compromise her diabetes. She said the nurse told her It would not hurt if I missed a few days of having my blood sugar checked. She said I wished they would have acknowledged me and came to me to tell me what was going on. She said she knew she could write a formal report but thought it was enough that she reported her concerns to the nurse and felt management let her concerns go unheard. She said the nursing home administrator (NHA) did not follow-up with her. B. Record review Review of the (MONTH) 2019 CPO revealed Resident #17 had an order for [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. -The MAR indicated [REDACTED]. III. Staff interviews Certified nurse aide (CNA) #9 was interviewed on 9/10/19 at 3:47 p.m. She said she had worked at the facility as needed (PRN) for one and a half years. She said if a resident had a concern or wanted to file a grievance she would tell the nurse, and then or notify the DON if not resolved. CNA #5 was interviewed on 9/11/19 at 10:37 a.m. She said she worked at the facility for [AGE] years. She said if a resident had a complaint or wanted to file a grievance she would get a complaint form and let the resident fill it out, and then she would turn it in to the nurse. CNA #7 was interviewed on 9/11/19 at 10:39 a.m. She said she worked at the facility for [AGE] years. She said if a resident had a complaint or concern she would report it to the nurse manager or DON and if they were not available she would report it to whoever was in charge. The registered dietician consultant (RDC) and registered dietician (RD) were interviewed on 9/11/19 11:32 at a.m. They said therapeutic diets were provided and included reduced concentrated sweets which meant the residents did not get served bread and were served ½ portion of the desert. The RD said she had provided Resident #17 education on two separate occasions regarding her diabetic diet to keep her blood glucose within normal limits. The NHA and DON were interviewed on 9/11/19 at 5:12 p.m. The NHA said resident complaints were kept anonymous. He said patients were oriented to where the complaint box was located and how to fill out the form upon admission and were told staff reviewed it daily. He said the resident could also report a grievance verbally. He said if something was communicated verbally and staff took action and the concern was taken care of then they would document and ensure the situation was resolved. He said if there was a concern documented in their complaint box he would date it is received and follow-up. The DON said she was not aware of the facility not having glucose strips available until she worked on Monday 9/2/19 as the floor nurse for Resident #17. She said that day she sent a staff member to purchase glucose strips, and made sure the resident had no signs or symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. She said she assumed the concern was resolved. -She said she was not made aware Resident #17's [MEDICATION NAME] did not arrive from pharmacy until 9/10/19 and she was not aware Resident #17 was upset about it. She said there was a fine line between grievances and an issue that arose, meaning a formal complaint versus informal and when the resident stated something, but then said don't worry about it because you fixed it. She said the follow-up for the [MEDICATION NAME] not being available was pending. They acknowledged the process had not been followed indicating Resident #17 was satisfied with the follow-up and there was no need for any further interventions. The NHA said last year they hired social services PRN to help with concerns as they arose, and because he was not well versed in Medicaid pending and outside resources. Social services was interviewed on 9/12/19 at 11:01 a.m. She said she worked at the facility on an as needed basis for one year and had been to the facility at least four times. She said during the intake on admission residents were asked if they had any social services issues to please request the NHA and the NHA would contact her for any relevant concerns.

Based on observations, record review and interviews, the facility failed to provide the services needed to maintain or improve the ability to carry out activities of daily living (ADLs) for one (#193) of two residents reviewed for ADLs out of 21 sample residents. Specifically, the facility failed to provide meal assistance per therapy recommendations for Resident #193. Findings include: I. Facility policy and procedure The Activities of Daily Living policy and procedure dated 12/17/2017 was provided by the director of nursing (DON) on 9/12/19 at 8:30 a.m. It read, in pertinent part, .Activities of daily living include the patient ' s ability to bathe, dress, grooming, oral care, transfer, ambulate, toilet, dining (include eating meals and snacks) .Based on each resident ' s comprehensive assessment, appropriate treatment and services are provided for all residents to help them maintain or improve their abilities to perform activities of daily living .participation in the program is based on resident ' s needs identified in the comprehensive assessments . II. Resident #193 Resident #193, age 93, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/31/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive two person assist for bed mobility, transfers, and toilet use and extensive one person assist for dressing, eating, and personal hygiene. [NAME] Observations On 9/10/19 during the morning meal, the following observations were made: --At 8:30 a.m., the resident was observed by herself at the reserved table. Her food was in front of her with minimal amount eaten from the bowls. --At 8:36 a.m., the resident placed her head down on the table. --At 8:41 a.m., a second resident was assisted to the reserved table; staff did not engage with Resident #193. --At 8:46 a.m., the resident was observed with her head still resting on the table. --At 8:51 a.m., the resident sat up in her wheelchair at the table. --At 8:52 a.m., the resident was assisted out of the dining room (DR) and back to her room. At no time during the observation did the resident receive cueing, encouragement, or assistance with the meal. On 9/10/19 during the noon meal, the following observations were made: --At 12:14 p.m., the resident arrived to the DR and was assisted to the table reserved for residents who required meal assistance. --At 12:15 p.m., the resident was observed to take a drink of the thickened juice without assistance or cueing from the staff. --At 12:17 p.m., the resident received her meal. The resident was observed to support her right forearm with her left hand as she was unable to lift the right arm independently to bring the spoonful of food into her mouth. --At 12:28 p.m., the resident was observed to stop eating her lunch meal. --At 12:29 p.m., the resident took two bites of food and then stopped. --At 12:32 p.m., the resident took a couple more bites. --At 12:33 p.m., the resident stopped eating. --At 12:35 p.m., the resident started eating again. --At 12:36 p.m., the resident stopped eating and was observed to place her head in her hands. --At 12:57 p.m., a staff member assisted the resident out of the DR and returned the resident to her room. Certified nurse aide (CNA) #8 documented on the flow sheet that the resident consumed 26-50% of the noon meal. At no time during the observation did the resident receive meal assistance from the CN[NAME] On 9/10/19 during the evening meal, the following observations were made: --At 5:42 p.m., the resident arrived to the DR and was assisted to the table reserved for residents who required meal assistance. --At 5:50 p.m., the resident received her meal and used a spoon to scoop the food from the bowls. Observed small portions of food on the spoon. --At 6:00 p.m., CNA#12 provided meal assistance to the resident. --At 6:03 p.m., the resident stopped eating. The CNA asked the resident if she was finished. The resident did not answer. The CNA gave the resident one more bite of food, immediately put the spoon on the table and proceeded to move the resident away from the table and out of the DR. The resident was only allowed 21 minutes to eat her meal, with assistance provided for just three of those 21 minutes. B. Record review The hospital discharge summary dated 8/24/19 revealed Resident #193 was evaluated by speech therapy (ST) and noted to have dysphagia (difficulty swallowing with increased risk of aspiration) and was placed on a honey thickened liquid. The speech-language pathology (SLP) evaluation and plan of care (P[NAME]) dated 8/26/19 showed the resident had a [DIAGNOSES REDACTED]. The resident was unaware of the swallowing deficit and needed to be fed by staff. The SLP progress note dated 8/27/19 revealed the resident required maximum assistance and monitored for all eating activities related to bolus (a small rounded mass of a substance, especially of chewed food at the moment of swallowing) size as well as physical assistance from the staff. The SLP progress note dated 9/8/19 showed the resident continued to show difficulty clearing the bolus even with sips of liquid between between bites. The ST recommended the resident be monitored at all times while eating, encouraged to take small bites one at a time with visuals and coaching. The (MONTH) 2019 treatments administration record (TARS) revealed Resident #193 admitted to the facility on [DATE] weighing 108 pounds (lbs). On 8/28/19, Resident #193 weighed 102.5, 5.09% weight loss since admission. The registered dietician (RD) started the resident on five ounces of boost pudding once a day as a supplement. On 9/4/19, Resident #193 weighed 95 lbs, 12.04 % weight loss since admission. The RD started the resident on four ounces of medication pass (med pass; this additional intake can mean weight maintenance or weight gain) twice a day related to inadequate meal intake. During the interview with the RD on 9/11/19 at 11:33 a.m., she said it was better if the resident received calories from food rather than supplements. She said the resident needed more encouragement and assistance during meals. The MD progress note dated 8/29/19 revealed Resident #193 had a [DIAGNOSES REDACTED]. The MD progress noted dated 9/3/19 revealed the resident continued to be on honey thickened liquids and followed by ST. The care plan revised on 9/3/19 showed an activities of daily living (ADL) goal for meals and nutritional status related to swallowing problems. The care plan revealed the resident required extensive one person assistance for meals. The comprehensive assessment dated [DATE] revealed the resident required extensive two person assistance for bed mobility, transfers, and toilet use and extensive one person assistance for dressing, eating, and personal hygiene. The plan of care (P[NAME]) reponses entered by the certified nursing aides (CNAs) for meal assistance revealed: --On 9/9/19 at 12:36 p.m., the resident ate the lunch meal with supervision and set-up from the staff. --On 9/9/19 at 3:46 p.m., the resident ate with supervision and set-up from the staff. --On 9/11/19 at 1:37 p.m., the resident ate the lunch meal with supervision and set-up from the staff. --On 9/11/19 at 6:12 p.m., the resident ate the dinner meal with supervision and set-up from the staff. --On 9/12/19 at 9:22 a.m., the resident ate the breakfast meal with supervision and set-up from the staff. Resident #193 only received supervision and set-up assistance for each meal, when in fact, she should have received extensive assistance per the care plan and MDS. C. Staff interviews CNA #13 was interviewed on 9/11/19 at 8:38 a.m. She said the resident required encouragement during meals. She was not certain what the care plan said about the level of assistance the resident required and usually found out from therapy. CNA #8 was interviewed on 9/11/19 at 9:25 a.m. She said the resident required supervision assistance for meals. Licensed practical nurse (LPN) #1 was interviewed on 9/11/19 at 9:43 a.m. She said the level of assistance varied throughout the week. There were days when the resident required only cueing and other days she was not willing to pick up the utensil and required extensive assistance. She said most of the time the resident required encouragement and assistance during meals. ST was interviewed on 9/12/19 at 12:56 p.m. She said the level of assistance the resident required varied, dependent on the alertness of the resident. When the resident admitted to the facility, she needed to be fed by the staff. She said even though the resident has made progress and was now able to feed herself, she still required encouragement and cues to take small bites. She said the resident still needed to be monitored during meals. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 9/12/19 at 1:33 p.m. They said therapy provided recommendations for meal assistance after the resident was evaluated. There were always two float CNAs in the DR. If a resident required continual meal assistance, the float CNA sat with the resident until the floor CNA was available. She said a staff member was with the resident at all times during meals. The DON said the meal assistance table was placed close to the serving window purposely, as staff members were always present and able to provide cueing and encouragement to the resident. The DON thought the resident only required close supervision and was not aware of the therapy recommendation to monitor the resident at all times during meals Follow-up The DON would request that a therapy order or recommendation be written and communication be provided to nursing if there was a change in the level of assistance a resident required during meals. This would aid in ensuring follow-through that the change had been implemented. Education would be provided to the nursing staff when there was a change in the level of assistance recommended by therapy.

Based on observation, interview, and record review, the facility failed to provide sanitary catheter care for two (#95 and #142) of four residents reviewed for indwelling catheters, out of 21 sample residents. Specifically, the facility failed to: -Perform hand hygiene before donning, and after doffing gloves; -Perform hand hygiene before and after emptying the urine drainage bag; -Prevent contamination of the tip of the urine drainage bag during emptying it; and -Sanitize the tip of the urine drainage bag after emptying it. Findings include: I. Facility policy and training material According to the facility policy for Bowel and Bladder Assessment, Catheter Utilization dated 2/27/18, provided by the nursing home administrator (NHA) on 9/12/19 at 2:30 p.m., it identified residents with indwelling catheters would be assessed daily during cares to ensure appropriate treatment and preventative techniques were instituted. According to the facility training material undated, Entry Pathway for Microbes, provided by the director of nursing (DON) on 9/12/19 at 2:45 p.m., it identified: -Entry pathways for microbes included the contamination of the urine collection bag and the subsequent movement of bacteria up the catheter; -Hand hygiene was to be performed prior to donning gloves, accessing the drainage system, and emptying the drainage bag; -Hand hygiene was to be performed after accessing the drainage system and emptying the drainage bag; -Only trained staff were to empty the urine collection bag; and -The catheter outlet valve was not to be contaminated during the emptying of the urine collection bag; the spigot (catheter outlet valve) was not to touch the container into which the urine was drained. II. Professional reference On 9/12/19 at 2:45 p.m. the DON identified the facility utilized Lippincott as its professional reference for catheter care and hand hygiene. According to Lippincott's Nursing Center, Catheter-Associated Urinary Tract Infection (CAUTI) Awakenings, (2019), retrieved from: https://www.nursingcenter.com/journalarticle?Article_ID= 27&Journal_ID= &Issue_ID= 95, it identified: -Only properly trained persons were to maintain catheters; -Following sterile insertion, a closed drainage system was to be maintained; and -Hand hygiene was to be maintained. According to Lippincott's Nursing Center, The patient/consumer experience of partnering with health care professionals with hand hygiene compliance: a systematic review protocol, (2015), retrieved from: https://www.nursingcenter.com/journalarticle?Article_ID= 09&Journal_ID= 80&Issue_ID= 93, it identified: -Hands played a role in the incidence of infection and the spread of microorganisms, as infectious agents could be transmitted by touch; -Hand hygiene was considered to be one of the most important infection control actions to help minimize the risk of infection; and -Improved hand hygiene practices were associated with sustained decrease in the incidence of infections. III. Resident #95 [NAME] Resident status Resident #95, was over [AGE] years of age, and was admitted on [DATE]. The (MONTH) 2019 computerized physician orders [REDACTED]. According to the 9/2/19 admission progress note, provided by the NHA on 9/12/19 at 2:30 p.m., Resident #95 was alert and oriented to: person, place, time, and situation. B. Observation An observation on 9/10/19 at 10:23 a.m. revealed certified nurse aide (CNA) #1 entered Resident #95's room and donned gloves without performing hand hygiene. After she retrieved the graduated cylinder from his restroom, she opened Resident #95's Foley catheter leg drainage bag and let the bag's drain tip touch the graduated cylinder while urine drained out of the bag. She wiped the tip with toilet paper and did not sanitize the tip. She emptied his urine in the toilet, doffed her gloves and donned another pair of gloves without performing hand hygiene. She assisted him into bed, doffed the gloves, and did not perform hand hygiene. With her bare hands, CNA #1 touched his bed control, television remote, and his water pitcher. After that she performed hand hygiene. An observation made on 9/11/19 at 3:40 p.m. revealed CNA #2 entered Resident #95's room and donned gloves without performing hand hygiene. She retrieved the graduated cylinder from the restroom, she opened Resident #95's Foley catheter leg drainage bag and let the bag's drain tip touch the graduated cylinder while urine drained out of the bag. She shook the drainage tip and let urine drops fall off of it. She did not sanitize the tip of drainage bag. She emptied his urine in the toilet and doffed her gloves. Then she donned another pair of gloves, without performing hand hygiene, then assisted him into bed. C. Record review According to the (MONTH) 2019 CPO Resident #95 had an order to receive Foley catheter care every shift. The care plan, initiated on 9/3/19, identified he had a risk for infection from his Foley catheter, due to [MEDICAL CONDITION]. Interventions included to provide catheter care as needed. D. Staff interviews CNA #1 was interviewed on 9/10/19 at 10:35 a.m. She said she was supposed to complete hand hygiene when entering and exiting resident rooms, and in between glove changes. She was unable to identify how to handle the tip of the urine drainage bags when residents' urine was drained from it. She said she used the toilet paper to catch the urine when it dripped from the tip of the drainage bag. CNA #2 was interviewed on 9/11/19 at 3:55 p.m. She said she received hand washing and glove usage training during monthly facility meetings. She said she was supposed to use hand sanitizer before entering and exiting resident rooms and in between wearing gloves. She did not recall when she received catheter care training. CNA #3 was interviewed on 9/11/19 at 3:45 p.m. She said she received hand washing and glove usage training during monthly facility meetings. She said she was supposed to use hand sanitizer before entering and exiting resident rooms and in between wearing gloves. She said she had drained urine drainage bags for facility residents who had catheters. She said to drain a urine drainage bag she needed to wash her hands, don gloves, and then drain the Foley catheter drainage bag. She said it was okay to let the urine drainage bag tip rest on the collection container used to catch the urine. She said it was okay to wipe the tip of the urine drainage bag with a regular wipe after urine was drained from it. She did not identify the need to sanitize the tip of the drainage bag after urine was drained from it. She said she could not recall the last time she had Foley catheter care training. IV. Resident #142 [NAME] Resident status Resident #142, was less than [AGE] years of age, and was admitted on [DATE]. The (MONTH) 2019 CPO revealed [DIAGNOSES REDACTED]. According to the 9/2/19 admission progress note, provided by the NHA on 9/12/19 at 2:30 p.m., Resident #142 had a Foley catheter, was alert and oriented, and was able to express his needs. B. Observation An observation on 9/12/19 at 11:57 a.m. revealed CNA #4 entered Resident #142's room and donned gloves without performing hand hygiene. He retrieved the graduated cylinder from his restroom, he opened Resident #142's Foley catheter leg drainage bag and let the bag's drain tip touch the graduated cylinder while urine drained out of the bag. He grabbed a tissue from the tissue box in the resident's room and wiped the tip of the urin bag with tissue. He did not sanitize the tip. An interview could not be obtained by him due to he had to answer the activated call lights on the unit Resident #142 resided on. C. Record review According to the (MONTH) 2019 CPO Resident #142 had an order to receive indwelling catheter care every shift. The care plan, initiated on 9/10/19, identified he had an indwelling catheter due to [MEDICAL CONDITION]. Interventions included to provide catheter care at least once per shift. D. DON interview The DON was interviewed on 9/12/19 at 1:54 p.m. She said staff should perform hand hygiene before entering and exiting resident rooms, between care delivered, and between glove changes; per infection control procedures. She said the tip of the urine drainage bags were to be sanitized with alcohol wipes per infection control procedures after staff drained urine from the bag. She said staff were provided catheter care training using hand-outs with step-by-step pictorial instructions on how to follow infection control procedures. The DON was interviewed a second time on 9/12/19 at 2:10 p.m. She said she planned to re-educate and re-train her staff on hand hygiene, glove usage, catheter care, and infection control procedures.

Based on observation, record review and interviews, the facility failed to ensure one (#193) of one residents reviewed for oxygen therapy out of 21 sample residents was provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to ensure a physician's orders [REDACTED].#193. Findings include: I. Professional references According to Potter/Perry, Fundamentals of Nursing, ninth edition, Elsevier, Canada, (YEAR), p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Facility policy and procedure The Oxygen Administration policy and procedure dated 9/4/2015 was provided by the director of nursing (DON) on 9/12/19 at 8:30 a.m. It read, in pertinent part, .Only qualified personnel administer oxygen in accordance with a physician's order [REDACTED].the physician's order [REDACTED]. [NAME] Resident #193 Resident #193, age 93, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/31/19 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required extensive two person assist for bed mobility, transfers, and toilet use and extensive one person assist for dressing, eating, and personal hygiene. B. Observations On 9/9/19 at 9:01 a.m., the resident was observed in her room. She sat in her wheelchair next to the bed. The resident was wearing a nasal cannula (NC) and oxygen was set at a rate of two liters per minute (LPM). On 9/9/19 at 11:54 a.m., the resident was assisted to the dining room for the noon meal. The resident was wearing a NC and oxygen was provided by a portable tank that hung from the back of the resident ' s wheelchair. The portable tank was set at a rate of two LPM. On 9/10/19 at 8:30 a.m., the resident sat at the assisted eating table with her head down on the table. The resident was wearing a NC and oxygen was set at a rate of two LPM. On 9/10/19 at 10:44 a.m., the resident was observed in her room. She sat in her wheelchair next to the bed. The resident was wearing a NC and oxygen was set at a rate of two LPM. On 9/10/19 at 12:15 p.m., the resident was assisted to the dining room for the noon meal. The resident was wearing a NC and oxygen was provided by a portable tank that hung from the back of the resident ' s wheelchair. The portable tank was set at a rate of two LPM. On 9/10/19 at 1:53 p.m., the resident was observed lying in bed in her room. The resident was wearing a NC and oxygen was set at a rate of two LPM. On 9/10/19 at 5:42 p.m., the resident was assisted to the dining room for the evening meal. The resident was wearing a NC and oxygen was provided by a portable tank that hung from the back of the resident ' s wheelchair. The portable tank was set at a rate of two LPM. On 9/11/19 at 10:38 a.m., the resident was in her room visiting with family members. The resident was wearing a NC and oxygen was set at a rate of two LPM. C. Record review The (MONTH) 2019 computerized physician orders [REDACTED].>The hospital discharge summary dated 8/24/19 revealed Resident #193 was assessed on room air with an oxygen saturation level of 94%. The facilities admission observation report dated 8/24/19 at 6:24 p.m., revealed Resident #193 used a continuous positive airway pressure ([MEDICAL CONDITION]) machine and used oxygen, delivered by a NC with activity and at rest. Documented vitals were inconsistent and revealed the following: --On 8/25/19 at 2:29 p.m., oxygen saturation of 92% with no oxygen use. --On 8/26/19 at 6:13 a.m., oxygen saturation of 91% with no oxygen use. --On 9/1/19 at 6:20 a.m., oxygen saturation of 90% with no oxygen use. --On 9/6/19 at 3:15 p.m., oxygen saturation of 91% with 2 LPM of oxygen; administered without an order. --On 9/7/19 at 2:27 p.m., oxygen saturation of 97% with no oxygen use. --On 9/9/19 at 3:52 p.m., oxygen saturation of 95% with no oxygen use. --On 9/9/19 at 4:09 p.m., oxygen saturation of 92% with 2 LPM of oxygen; administered without an order. --On 9/10/19 at 6:28 a.m., oxygen saturation of 90% with no oxygen use. --On 9/11/19 at 5:03 p.m., oxygen saturation of 96% with no oxygen use; order for oxygen was submitted at 3:34 p.m. The doctor ' s (MD) progress note dated 8/27/19 revealed the resident was assessed on room air with an oxygen saturation level of 96%. The MD progress note dated 8/29/19 revealed the resident was assessed on two LPM of oxygen with an oxygen saturation rate of 98%. The MD progress noted dated 9/3/19 revealed the resident was assessed on two LPM of oxygen with an oxygen saturation level of 95%. The five day admission MDS assessment dated [DATE] revealed the resident received oxygen therapy both prior to and after admission to the facility. The 14 day MDS assessment dated [DATE] revealed the resident continued to receive oxygen therapy. Nurse progress note dated 9/7/19 revealed the resident received two LPM of oxygen via nasal cannula. The care plan revised on 9/3/19 showed oxygen therapy goals of adequate ventilation maintained as evidenced by oxygen saturation greater than 90%. The goal was that the resident would be free from signs and symptoms of respiratory distress with interventions of monitor for shortness of breath, oxygen as indicated, elevate the head of bed (HOB) to maximize air exchange, pulse oximeter per doctor (MD) orders, and titrate oxygen per MD orders. The care plan failed to include interventions of liter flow with parameters, frequency, and duration of oxygen treatment as required by the facility's policy and procedure. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/11/19 at 3:15 p.m. She said Resident #193 was on two LPM of oxygen, delivered via NC. The RN reviewed the residents medical chart and confirmed there was not an order for [REDACTED].>The director of nursing (DON) was interviewed on 9/12/19 at 2:28 p.m. She said the facility had standing orders for residents who admitted without an order for [REDACTED].#193 did not have an order for [REDACTED].>Follow-up The LPN submitted an order for [REDACTED].

Based on interviews and record review, the facility failed to ensure prompt efforts were made to resolve grievance for one (#25) resident reviewed for complaints/grievances out of a total 21 sample residents. Specifically, the facility failed to have documentation the resident's complaint was investigated and the resident was informed of the steps taken to resolve her complaint. Findings include: I. Grievance policy The Grievance policy was provided by the nursing home administrator (NHA) on 9/11/18 at approximately 11 a.m. It read in pertinent part: Patients or representatives may voice grievances without discrimination or reprisal from the facility. A prompt invitation and resolution will be made for all grievances patients may have. Grievances include those related to treatment furnished, treatment that has not been furnished and behavior of other patients. Grievances may be oral or written. All grievances are confidential. Patients may file grievances anonymously or verbally. The patient or representative has the right to obtain a written decision regarding his or her grievance. II. Resident #25 The resident, age 73, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 8/28/18 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance for toileting and limited assistance for bed mobility, transfers and locomotion on the unit. A. Resident interview The resident was interviewed on 9/10/18 at 10:30 a.m. She said about a week ago, she went into the NHA ' s office and reported she did not receive her pain medication and she was hurting. (Cross-reference F697) She said the NHA told her that he would investigate and follow up with her. She said she had not heard anything regarding what she had reported to the NHA. She said she did not feel that her concern was addressed appropriately. She said the facility should order pain medication on time so they do not run out. She said I have shingles and it hurt. B. Staff interview and record review The NHA was interviewed on 9/12/18 9:00 a.m. He said he was responsible for investigating grievances. He confirmed the resident came into his office in her wheelchair and was upset. He said she reported to him that she was hurting and she had not gotten her pain medication. -He said the resident reported to him that she turned on her call light on and the certified nurse aide (CNA) responded to answer her light. He said the resident said she told the CNA to tell the nurse that she needed her pain medication and the nurse did not give her her pain medication. -He confirmed that he told the resident he would investigate her complaint and follow up with her but said he did not consider the resident ' s complaint as formal and she indicated she did not want a written decision on her complaint. He said he investigated and he followed up with the resident verbally. He said he did not document anything regarding the investigation.

Based on record review and staff interviews, the facility failed to provide care and services for a non-pressure related wound in accordance with professional standards of practice for one (#208) of two residents reviewed for skin conditions out of a total 21 sample residents. Specifically, the facility failed to adequately assess an open wound upon admission. Findings include: Resident #208 A. Resident status Resident #208, age 85, was admitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 9/9/18 admission nursing assessment revealed the resident was alert and cooperative. He displayed short and long term memory problems and had impaired decision making abilities. He required assistance with his activities of daily living (ADLs) and used a walker and a wheelchair for mobility. He had extensive bruising in various stages of healing and scabbed over abrasion - OTA (open to air) first 3 (three) toes on L (left) foot have abrasions (scabbed over) to top of toes. Second and 3rd toes on right foot with scabbed over abrasions to top of foot. Open area to L / R (right) great be approximately the size of a dime. B. Record review 1. Care plan The baseline person centered care plan, dated 9/9/18, revealed the resident was at risk for alterations in skin integrity. The care plan failed to identify the resident had an open wound on his right foot. 2. Admission assessment The 9/9/18 nursing admission assessment read, open area to L (left) side of foot/ R (right) great be approximately the size of a dime. The assessment failed to provide an accurate measurement or detailed description of the wound. C. Staff interviews The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 9/11/18 at 3:30 p.m. They reported the admission nurses performed the initial wound assessment. They reported the DON or ADON, both wound certified, would then assess the wound. They stated the resident was admitted on Sunday (9/9/18) and they had not had the chance to assess the wound. They stated if a resident was admitted on a weekend, they would (usually) complete the follow up assessment on Monday morning. They reported both the admission nurses were licensed practical nurses (LPNs), neither of whom were wound certified. The DON was again interviewed on 9/11/18 at 4:23 p.m. She stated, based on interview with the resident, the open wound on his foot was caused by him dragging himself across the floor prior to his admission. She stated the nurses should have provided accurate measurements, documented in centimeters (cm), and a description of the wound in order to accurately assess the wound for healing. D. Resident observation The wound was covered with a dressing throughout the survey process as ordered by the physician.